Renal Disorders in Pregnancy: Core Curriculum 2019

Abstract

As the incidence of chronic kidney disease increases and women pursue pregnancy at more advanced ages, the management of kidney disease in pregnancy has become increasingly relevant to the practicing nephrologist. Women with kidney disorders face several challenges in pregnancy due to increased physiologic demands on the kidney and risk for disease progression, the potential teratogenicity of medications, and the increased risk for complications such as preeclampsia and preterm delivery. Challenges posed by an underlying disease process in pregnancy, such as autoimmune disease or diabetes mellitus, necessitate an interdisciplinary team to ensure good maternal and fetal outcomes. Rates of acute kidney injury in pregnancy are generally declining worldwide, but remain a significant public health concern in developing countries. Pregnancy may also be the first time that a woman has kidney disease or hypertension diagnosed. An understanding of what constitutes normal physiologic changes in pregnancy is critical in a diagnostic evaluation. In this review, we review physiologic changes in pregnancy, causes and management of acute kidney injury in pregnancy, hypertensive disorders of pregnancy, and how to care for women with chronic kidney disease of various causes, including the use of antihypertensives and immunosuppressants.

Keywords: Pregnancy; acute kidney injury (AKI); autoimmune disease; chronic kidney disease (CKD); diabetes mellitus; dialysis; hypertension; immunosuppression; kidney transplantation; maternal fetal complications; preeclampsia; renal disease; renal outcomes; review.

Figure 1:

Light microscopy image, hematoxylin and eosin stain, demonstrating acute cortical necrosis in the setting of pregnancy. Scale bar: 100 microns (see Case 1).

Figure 2:

Kidney biopsy image from a 30 yo women with hemolysis, elevated liver enzymes and low platelet (HELLP) syndrome. Kidney biopsy was performed due to acute kidney injury and revealed severe acute tubular necrosis, with hemoglobin casts, likely related to hypoperfusion and hemolysis. (Light microscopy image demonstrating hemoglobin-containing casts in renal tubules and acute tubular necrosis. Scale bar: 100 microns)

Figure 3:

Computed tomography (CT) images from a young woman with a history of HIV-associated nephropathy who developed heavy proteinuria (11 g/d) at the time of delivery and developed an acute left-sided renal vein thrombosis 5 weeks post-partum.