The Impact of Preeclampsia in Lupus Nephritis

ABSTRACT

Introduction

Women with systemic lupus erythematosus (SLE), particularly those with lupus nephritis (LN), remain at high risk for adverse pregnancy outcome. Although in the last decades maternal and fetal outcomes have improved dramatically, preeclampsia remains a major cause of maternal and perinatal morbidity and mortality.

Areas covered

A narrative review of literature was conducted, underlying the importance of pre-conception counseling, and focusing on the correlation between preeclampsia and LN. The clinical characteristics of preeclampsia were described, with emphasis on risk factors in LN and the differential diagnosis between preeclampsia and lupus flares. Additionally, the prevention and treatment of preeclampsia were discussed, as well as the management of short-term and long-term consequences of preeclampsia. We highlight the importance of a pre-pregnancy counseling from a multidisciplinary team to plan pregnancy during inactive SLE and LN.

Expert opinion

Further studies are needed to evaluate the long-term consequences of pregnancy in LN. Considering that preeclamptic patients can be at high risk for long-term renal failure, we suggest renal checkup for at least 6–12 months after delivery in all patients.

KEYWORDS:

• Arterial hypertension
• chronic kidney disease
• eclampsia
• lupus flare
• lupus nephritis
• preeclampsia
• systemic lupus erythematosus

Article highlights

• Preeclampsia is a multisystem disorder of pregnancy defined as new-onset hypertension and proteinuria, which occurs after the 20^th gestational week. Preeclampsia is associated with maternal morbidity and mortality. Chronic kidney disease and autoimmune diseases, such as systemic lupus erythematous (SLE) and antiphospholipid syndrome (APS), are some of the risk factors for preeclampsia.

• Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that affects mostly female patients at reproductive age. Patients with SLE, particularly those with lupus nephritis (LN) are at high risk for adverse pregnancy outcome (APO) and for preeclampsia. LN is one of the most important determinants of preeclampsia in SLE patients.

• In patients with LN, a high rate of renal flares is reported to occur during pregnancy. Differential diagnosis between renal flares and preeclampsia is often complicated since arterial hypertension and proteinuria are typical manifestations of both renal flares and preeclampsia. In renal flares, proteinuria is generally associated with active urinary sediment with red blood cells and casts, low serum C3 and C4 levels, high levels of anti-DNA and anti-C1q antibodies and extrarenal SLE manifestations.

• To achieve good pregnancy outcome and to prevent preeclampsia, a careful evaluation of risk factors should be done pre-conception. Pregnancy should be planned during inactive LN and hydroxychloroquine should be administered throughout pregnancy to decrease the risk of flares. Low-dose aspirin and antihypertensive treatment are also strongly recommended to prevent preeclampsia in women with moderate or high risk.

• Rapid diagnosis of preeclampsia, early treatment of acute hypertension and the use of magnesium sulfate may prevent the development of eclampsia, but definitive treatment of preeclampsia is delivery.

• Preeclampsia is associated with acute and chronic long-term complications both for women and child. Some reports show the correlation between end-stage kidney disease (ESKD) and preeclampsia in patients with LN, but larger studies are needed to elucidate the long-term effects of preeclampsia on renal disease.

• Although pregnancy is still risky for LN women, an expert management starting with pre-pregnancy counselling and with planned pregnancies, in addition to rapid diagnosis of preeclampsia and of lupus flares and early treatment of complications, are essential to achieve good maternal outcomes.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.