Pregnancy in CKD stages 3 to 5: fetal and maternal outcomes.
BACKGROUND
Prognostic criteria to inform women with moderate to severe renal insufficiency who wish to bear children are not well established.


METHODS
Longitudinal multicenter cohort study.


METHODS
Nondiabetic white women with pregnancies proceeded beyond the 20th week and estimated glomerular filtration rate (GFR) less than 60 mL/min/1.73 m(2) (<1 mL/s/1.73 m(2)) before conception.


METHODS
Baseline GFR and proteinuria (exposure); other clinical characteristics at conception (covariates).


METHODS
Difference in GFR decreases before conception versus after delivery (mixed linear models); low birth weight (<2,500 g), and maternal renal survival (logistic and Cox regressions).


RESULTS
49 women were studied. Mean serum creatinine and GFR at conception were 2.1 +/- 1 (SD) mg/dL (186 +/- 88 micromol/L) and 35 +/- 12 mL/min/1.73 m(2) (0.58 +/- 0.2 mL/s/1.73 m(2)), respectively. Overall mean GFR after delivery was less than before conception (30 +/- 13.8 versus 35 +/- 12.2 mL/min/1.73 m(2) [0.50 +/- 0.23 versus 0.58 +/- 0.20 mL/s/1.73 m(2)]; P < 0.001), but the rate of GFR decrease did not change (0.55 +/- 0.8 versus 0.50 +/- 0.3 mL/min/mo [0.0092 +/- 0.013 versus 0.0083 +/- 0.005 mL/s/mo]; P = 0.661). Independent of potential confounders, the combined presence of baseline GFR less than 40 mL/min/m(2) (<0.67 mL/s/m(2)) and proteinuria with protein greater than 1 g/d, but not either factor alone, predicted faster GFR loss after delivery compared with before conception (1.17 +/- 1.23 versus 0.55 +/- 0.39 mL/min/mo; difference, 0.62 mL/min/mo; 95% confidence interval [CI], 0.27 to 0.96 mL/min/mo [0.020 +/- 0.021 versus 0.0092 +/- 0.007 mL/s/mo; difference, 0.10 mL/s/mo; 95% CI, 0.005 to 0.016 mL/s/mo]). The presence of both risk factors, but not either alone, also predicted shorter time to dialysis therapy or GFR halving (N = 20; hazard ratio, 5.2; 95% CI, 1.7 to 15.9) and low birth weight (N = 29; odds ratio, 5.1; 95% CI, 1.03 to 25.6).


CONCLUSIONS
Generalizability to other settings; study power.


CONCLUSIONS
In women with renal insufficiency, the presence of both GFR less than 40 mL/min/1.73 m(2) (<0.67 mL/s/m(2)) and proteinuria with protein greater than 1 g/d before conception predicts poor maternal and fetal outcomes.
Imbasciati
Enrico
E
Renal Unit, Ospedale di Lodi, Italy. enrico.imbasciati@fastwebnet.it
Gregorini
Gina
G
Cabiddu
Gianfranca
G
Gammaro
Linda
L
Ambroso
Giancarlo
G
Del Giudice
Antonio
A
Ravani
Pietro
P
D000328:Adult; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D003404:Creatinine / Q000097:blood; D018450:Disease Progression; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D007676:Kidney Failure, Chronic / Q000097:blood / Q000503:physiopathology; D007677:Kidney Function Tests; D015999:Multivariate Analysis; D011247:Pregnancy; D011248:Pregnancy Complications / Q000097:blood / Q000503:physiopathology; D011256:Pregnancy Outcome; D011379:Prognosis; D011507:Proteinuria / Q000503:physiopathology
D000806:Angiotensin-Converting Enzyme Inhibitors; D003404:Creatinine