Perinatal Outcomes in Women with Chronic Kidney Diseases

Abstract

Objective To assess maternal and neonatal outcomes in women with chronic kidney disease (CKD) at a referral center for high-risk pregnancy.

Methods A retrospective cohort of pregnant women with CKD was followed at the Women's Hospital of Universidade Estadual de Campinas, Brazil, between 2012 and 2020. Variables related to disease etiology, treatment duration, sociodemographic variables, lifestyle, other associated diseases, obstetric history, and perinatal outcomes were assessed. The causes of CKD were grouped into 10 subgroups. Subsequently, we divided the sample according to gestational age at childbirth, as preterm and term births, comparing maternal and neonatal outcomes, and baseline characteristics as well as outcomes among such groups.

Results A total of 84 pregnancies were included, in 67 women with CKD. Among them, six pregnancies evolved to fetal death, five to miscarriage, and one was a twin pregnancy. We further analyzed 72 single pregnancies with live births; the mean gestational age at birth was 35 weeks and 3 days, with a mean birth weight of 2,444 g. Around half of the sample (51.39%) presented previous hypertension, and 27.7% developed preeclampsia. Among the preterm births, we observed a higher frequency of hypertensive syndromes, longer maternal intensive care unit (ICU) stay in the postpartum period, higher incidence of admission to the neonatal ICU, higher neonatal death, lower 5-minute Apgar score, and lower birth weight.

Conclusion This study demonstrates increased adverse outcomes among pregnancies complicated by CKD and expands the knowledge on obstetric care among such women in an attempt to reduce maternal risks and identify factors related to prematurity in this population.

Resumo

Objetivo Avaliar os desfechos maternos e neonatais em mulheres com doença renal crônica (DRC) em um centro de referência para gestação de alto risco.

Métodos Coorte retrospectiva de gestantes com DRC acompanhadas no Hospital da Mulher da Universidade Estadual de Campinas, Brasil, entre 2012 e 2020. Variáveis relacionadas à etiologia da doença, duração do tratamento, variáveis sociodemográficas, estilo de vida, outras doenças associadas, história obstétrica, número de consultas de pré-natal e os resultados perinatais foram avaliados. As causas da DRC foram agrupadas em 10 subgrupos. Posteriormente, dividimos a amostra de acordo com a idade gestacional no parto, pois os nascimentos pré-termo e a termo comparam os desfechos maternos e neonatais bem como as características basais e desfechos entre esses grupos.

Resultados Um total de 84 gestações foram incluídas em 67 mulheres com DRC. Dentre elas, seis gestações evoluíram para óbito fetal, cinco para aborto espontâneo, e uma era gestação gemelar. Foram analisadas ainda 72 gestações únicas, com nascidos vivos; a idade gestacional média ao nascer foi de 35 semanas e 3 dias, e o peso médio ao nascer foi 2.444 g. Cerca de metade da amostra (51,39%) apresentava hipertensão prévia e 27,7% desenvolveram pré-eclâmpsia. Entre os casos de prematuridade (34 casos), observamos maior frequência de síndromes hipertensivas, mais dias de internação materna na UTI no pós-parto, maior incidência de internação na UTI neonatal, óbito neonatal, menor índice de Apgar de 5 minutos e menor peso ao nascimento.

Conclusão Este estudo demonstra o aumento de desfechos adversos em gestações complicadas por DRC e amplia o conhecimento sobre cuidados obstétricos entre essas mulheres na tentativa de reduzir os riscos maternos e identificar fatores relacionados à prematuridade nessa população.

Keywords

kidney disease - high-risk pregnancy - antenatal care - perinatal outcomes

Palavras-chave

doença renal - gravidez de alto risco - cuidado pré-natal - cuidados perinatais

Contributors

Marcus Vinicius Pinheiro Zilli: investigation, data curation and writing - original draft. Anderson Borovac-Pinheiro: methodology, data curation and writing - original draft. Maria Laura Costa: investigation, review & editing. Fernanda Garanhani Surita: conceptualization, methodology, data curation, supervision, review & editing. All authors approved the final version to be published.

Publication History

Received: 08 March 2022

Accepted: 19 May 2022

Article published online:
29 December 2022

• References

• 1 GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2020; 395 (10225): 709-733 DOI: 10.1016/S0140-6736(20)30045-3.
• 2 Hui D, Hladunewich MA. Chronic kidney disease and pregnancy. Obstet Gynecol 2019; 133 (06) 1182-1194 DOI: 10.1097/AOG.0000000000003256.
• 3 Williams D, Davison J. Chronic kidney disease in pregnancy. BMJ 2008; 336 (7637): 211-215 DOI: 10.1136/bmj.39406.652986.BE.
• 4 Kumakura S, Okamoto K, Takeuchi S. , Yoshida M, Nakamichi T, Nagasawa T, et al. Kidney function, blood pressure and proteinuria were associated with pregnancy outcomes of pregnant women with chronic kidney disease: a single-center, retrospective study in the Asian population. Clin Exp Nephrol 2020; 24 (06) 547-556 DOI: 10.1007/s10157-020-01865-0.
• 5 Kattah A. Preeclampsia and kidney disease: deciphering cause and effect. Curr Hypertens Rep 2020; 22 (11) 91 DOI: 10.1007/s11906-020-01099-1.
• 6 Zhang JJ, Ma XX, Hao L, Liu LJ, Lv JC, Zhang H. A systematic review and meta-analysis of outcomes of pregnancy in CKD and CKD outcomes in pregnancy. Clin J Am Soc Nephrol 2015; 10 (11) 1964-1978 DOI: 10.2215/CJN.09250914.
• 7 Harel Z, Park AL, McArthur E. , Hladunewich M, Dirk JS, Wald R, et al. Prepregnancy renal function and risk of preterm birth and related outcomes. CMAJ 2020; 192 (30) E851-E857 DOI: 10.1503/cmaj.200089.
• 8 Conover WJ. Practical nonparametric statistics. 3rd ed. New York: John Wiley & Sons; 1999
• 9 Siegel S, Castellan Jr NJ. Estatística não-paramétrica para ciências do comportamento. 2a ed. Porto Alegre. Art Med 2006
• 10 Tabachnick BG, Fidell LS. Using multivariate statistics. 4th ed. Boston: Allyn and Bacon; 2001
• 11 Fleiss JL, Levin B, Paik MC. Statistical methods for rates and proportions. 3rd ed. Hoboken: John Wiley & Sons; 2003
• 12 Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008; 371 (9606): 75-84 DOI: 10.1016/S0140-6736(08)60074-4.
• 13 Piccoli GB, Cabiddu G, Attini R. , Vigotti FN, Maxia S, Lepori N, et al. Risk of adverse pregnancy outcomes in women with CKD. J Am Soc Nephrol 2015; 26 (08) 2011-2022 DOI: 10.1681/ASN.2014050459.
• 14 Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. N Engl J Med 1996; 335 (04) 226-232 DOI: 10.1056/NEJM199607253350402.
• 15 Cabiddu G, Castellino S, Gernone G. , Santoro D, Moroni G, Giannattasio M, et al. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy. J Nephrol 2016; 29 (03) 277-303 DOI: 10.1007/s40620-016-0285-6.
• 16 Marinho AW, Penha AP, Silva MT, Galvão TF. Prevalência de doença renal crônica em adultos no Brasil: revisão sistemática da literatura. Cad Saúde Coletiva. 2017; 25 (03) 379-88 DOI: 10.1590/1414-462×201700030134.
• 17 Kendrick J, Sharma S, Holmen J, Palit S, Nuccio E, Chonchol M. Kidney disease and maternal and fetal outcomes in pregnancy. Am J Kidney Dis 2015; 66 (01) 55-59 DOI: 10.1053/j.ajkd.2014.11.019.
• 18 Wang M, Chen S, He Y, Zhao M, Yang H, Chen Q. Low-dose aspirin for the prevention of severe preeclampsia in patients with chronic kidney disease: a retrospective study : This is the study for kidney and pregnancy. J Nephrol 2021; 34 (05) 1631-1639 DOI: 10.1007/s40620-021-01049-3.
• 19 Wiles K, Chappell LC, Lightstone L, Bramham K. Updates in diagnosis and management of preeclampsia in women with CKD. Clin J Am Soc Nephrol 2020; 15 (09) 1371-1380 DOI: 10.2215/CJN.15121219.
• 20 Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S. et al; International Society for the Study of Hypertension in Pregnancy (ISSHP). The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2018; 13: 291-310 DOI: 10.1016/j.preghy.2018.05.004.
• 21 Bartsch E, Medcalf KE, Park AL, Ray JG. High Risk of Pre-eclampsia Identification Group. Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies. BMJ 2016; 353: i1753 DOI: 10.1136/bmj.i1753.
• 22 Saudan P, Brown MA, Buddle ML, Jones M. Does gestational hypertension become pre-eclampsia?. Br J Obstet Gynaecol 1998; 105 (11) 1177-1184
• 23 The National Institute for Health and Care Excellence. Hypertension in pregnancy: diagnosis and management [Internet]. 2019 [cited 2022 Feb 1]. (NICE guideline; 133). Available from: www.nice.org.uk/guidance/ng133
• 24 Ray JG, Bartsch E, Park AL, Shah PS, Dzakpasu S. Estimated reductions in provider-initiated preterm births and hospital length of stay under a universal acetylsalicylic acid prophylaxis strategy: a retrospective cohort study. CMAJ Open 2017; 5 (02) E508-E516 DOI: 10.9778/cmajo.20160092.
• 25 Rolnik DL, Wright D, Poon LC. , O'Gorman N, Syngelaki A, de Paco Matallana C, et al. Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. N Engl J Med 2017; 377 (07) 613-622 DOI: 10.1056/NEJMoa1704559.
• 26 Pastore DEA, Costa ML, Parpinelli MA, Surita FG. A critical review on obstetric follow-up of women affected by systemic lupus erythematosus. Rev Bras Ginecol Obstet 2018; 40 (04) 209-224 DOI: 10.1055/s-0038-1625951.
• 27 Giordano JC, Parpinelli MA, Cecatti JG. , Haddad SM, Costa ML, Surita FG, et al. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One 2014; 9 (05) e97401 DOI: 10.1371/journal.pone.0097401.
• 28 de Jesús GR, Lacerda MI, Rodrigues BC. , Santos FC, Nascimento AP, Cristóvão Porto L, et al. Soluble Flt-1, placental growth factor, and vascular endothelial growth factor serum levels to differentiate between active lupus nephritis during pregnancy and preeclampsia. Arthritis Care Res (Hoboken) 2021; 73 (05) 717-721
• 29 Di Leo V, Capaccio F, Gesualdo L. Preeclampsia and glomerulonephritis: a bidirectional association. Curr Hypertens Rep 2020; 22 (05) 36 DOI: 10.1007/s11906-020-1033-9.
• 30 Rudey EL, Leal MDC, Rego G. Cesarean section rates in Brazil: Trend analysis using the Robson classification system. Medicine (Baltimore) 2020; 99 (17) e19880 DOI: 10.1097/MD.0000000000019880.
• 31 Boerma T, Ronsmans C, Melesse DY, Barros AJ, Barros FC, Juan L. , et al. Global epidemiology of use of and disparities in caesarean sections. Lancet 2018; 392 (10155): 1341-1348 DOI: 10.1016/S0140-6736(18)31928-7.