title: A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy.
abstract: Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.
authors.affiliation: Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy.
authors.forename: Gianfranca
authors.initials: G
authors.lastname: Cabiddu
authors.affiliation: Nephrology and Dialysis, Taormina Hospital, Taormina, Italy.
authors.forename: Santina
authors.initials: S
authors.lastname: Castellino
authors.affiliation: Nephrology, S. Maria Degli Angeli Hospital, Putignano, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Gernone
authors.affiliation: Nephrology and Dialysis, AOU "G. Martino", Messina, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Santoro
authors.affiliation: Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milano, Italy.
authors.forename: Gabriella
authors.initials: G
authors.lastname: Moroni
authors.affiliation: Dipartimento Nefrodialitico Città di Bari Hospital, Bari, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Giannattasio
authors.affiliation: Nephrology, Spedali Civili di Brescia, Brescia, Italy.
authors.forename: Gina
authors.initials: G
authors.lastname: Gregorini
authors.affiliation: Nephrology, Ospedale d'Ivrea, Ivrea, Italy.
authors.forename: Franca
authors.initials: F
authors.lastname: Giacchino
authors.affiliation: Obstetrics, Department of Surgery, University of Torino, Torino, Italy.
authors.forename: Rossella
authors.initials: R
authors.lastname: Attini
authors.affiliation: Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Loi
authors.affiliation: Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy.
authors.forename: Monica
authors.initials: M
authors.lastname: Limardo
authors.affiliation: Nephrology, Ospedale Fracastoro, San Bonifacio, Italy.
authors.forename: Linda
authors.initials: L
authors.lastname: Gammaro
authors.affiliation: Obstetrics, Department of Surgery, University of Torino, Torino, Italy.
authors.forename: Tullia
authors.initials: T
authors.lastname: Todros
authors.affiliation: Nephrology, ASOU San Luigi, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy. gbpiccoli@yahoo.it.|Nephrologie, Centre Hospitalier du Mans, Le Mans, France. gbpiccoli@yahoo.it.
authors.forename: Giorgina Barbara
authors.initials: GB
authors.lastname: Piccoli
mesh_terms: D003937:Diagnosis, Differential; D019317:Evidence-Based Medicine; D005260:Female; D005921:Glomerulonephritis / Q000628:therapy; D006801:Humans; D046110:Hypertension, Pregnancy-Induced / Q000209:etiology; D063130:Maternal Death; D011225:Pre-Eclampsia / Q000175:diagnosis; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis / Q000628:therapy*; D051436:Renal Insufficiency, Chronic / Q000150:complications / Q000175:diagnosis / Q000628:therapy*
keywords: Chronic kidney disease; Evidence based medicine; Hypertension; Pre-term delivery; Preeclampsia; Pregnancy; Proteinuria