Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases

Abstract

Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women.

Keywords: chronic kidney disease (CKD), dialysis; kidney transplantation; pregnancy; pregnancy complications.

Figure 1

The different “small babies”: Growth curve of small, small for gestational age (SGA), intrauterine growth restricted (IUGR) babies (Y axis: weight and reference curves; X axis: gestational weeks). Legend: (A) is a very small, early preterm normal for gestational age child; (B) is a very small, early preterm, SGA but harmoniously grown, preterm child (mother and father also of small body size); child (C) is a small, SGA, preterm child with a flattening of the growth curve. Although (B,C) are identified also as IUGR, flattening of the growth curve may have a different (unfavorable) meaning as for life-long complications. (Courtesy of R. Attini and P. Gaiotti).