Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby

Figures & data

Table 1 Staging of CKD (KDOQI)

Stage	Description	GFR (mL/min/1.73 m^2)
1	Abnormal renal morphology or function with normal or increased GFR	≥90
2	Abnormal renal morphology or function with mildly decreased GFR	60–89
3	Moderate decrease in GFR	30–59
4	Severe decrease in GFR	15–29
5	End-stage renal disease	<15 (or dialysis dependent)

Notes: CKD is defined as kidney damage with alteration in morphology, imaging, or function of the kidney, or, alternatively, an eGFR of <60 mL/min/1.73 m² for at least 3 months. Creatinine-based equations for eGFR may be applied to preconception creatinine samples, but are not validated for pregnant women, and may underestimate or overestimate eGFR in pregnancy. Preconception CKD stage is an important determinant of obstetric and perinatal outcomes and impact of pregnancy on maternal renal health. Copyright © 2002 National Kidney Foundation. Reproduced with permission from NKF KDOQI Guidelines; 2002. Available from: http://www2.kidney.org/professionals/KDOQI/guidelines_ckd/p4_class_g1.htm. Accessed October 4, 2015.¹⁰⁷

Abbreviations: CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; KDOQI, Kidney Disease Outcomes Quality Initiative.

Figure 1 Algorithm for pregnancy care in women with CKD.

Note: *Or more frequently if required.
Abbreviations: ACEI, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BMI, body mass index; BP, blood pressure; CKD, chronic kidney disease; DM, diabetes mellitus; GDM, gestational diabetes mellitus; SLE, systemic lupus erythematosus; STD, sexually transmitted disease.

Table 2 Recommendations for immunosuppressant medications in pregnancy

Drug	Pregnancy effects	Recommendation in pregnancy
Prednisolone	Maternal hypertension and GDM Risk of thymal hyperplasia and adrenal suppression in neonate with high doses	May be continued Avoid prolonged high doses
Azathioprine	No teratogenicity Unable to be activated by fetal liver	May be continued
Tacrolimus	Potential increased risk of GDM Risk of transient neonatal renal dysfunction and hyperkalemia	May be continued Monitor and adjust levels Early OGTT in pregnancy especially if combined with prednisolone Check neonatal biochemistry
Cyclosporine A	No teratogenicity Associated with maternal hypertension Reversible effect on fetal lymphocytes	May be continued Monitor and adjust levels
Mycophenolate mofetil	Teratogenic and embryopathic Multiple congenital defects of ears, digits, oral cavity Increased pregnancy loss	Cease 12 weeks prior to conception
Cyclophosphamide	Teratogenic in first trimester Affects ovarian function and fertility	Cease 12 weeks preconception Use in later pregnancy if critical to maternal life
Sirolimus Everolimus (mTOR inhibitors)	Animal studies suggest teratogenicity, effects on bone and fetal growth. Data remain very limited	Cease 12 weeks preconception due to lack of data to support safe use

Note: Data from Bramham et al,³⁹ KDIGO,⁸⁰ McKay et al,⁸⁶ Hebert et al,⁹³ Thiagarajan et al,⁹⁹ Sifontis et al,¹⁰⁸ and Tendron et al¹⁰⁹.

Abbreviations: GDM, gestational diabetes mellitus; mTOR, mammalian targets of rapamycin; OGTT, oral glucose tolerance test.

Table 3 Summary of RCOG guidance on contraceptive use in hypertension, diabetes, and SLE¹⁰⁴

Contraceptive method	Hypertension	Diabetes	SLE
Combined OCP	Risks outweigh benefits even in controlled hypertension Unacceptable risk if BP >160/100 mmHg or vascular disease present	Benefit outweighs risk in uncomplicated diabetes Risks outweigh benefits in diabetic nephropathy, retinopathy, or vascular disease	Benefit outweighs risk in uncomplicated disease Unacceptable to use in APLAS
Progesterone-only OCP	Acceptable to use Benefits outweigh risks if vascular disease present	Benefits outweigh risks	Benefit outweighs risk in uncomplicated SLE and APLAS
Subdermal implants	Acceptable to use Benefits outweigh risks if vascular disease present	Benefits outweigh risks	Benefit outweighs risk in uncomplicated SLE and APLAS
Injectable medroxyprogesterone	Acceptable to use if BP <160/100. Benefits outweigh risks at other levels of BP. Risks outweigh benefits if vascular disease present.	Benefit outweighs risk in uncomplicated diabetes	Benefit outweighs risk in uncomplicated SLE and APLAS
Levonorgestrel intrauterine device	Acceptable to use in controlled hypertension Benefits may outweigh risks in those with vascular disease	Benefits outweigh risks	Benefit outweighs risk in uncomplicated SLE and APLAS
Copper IUD	Acceptable to use	Acceptable to use	Acceptable to use

Notes: No guidelines are available for CKD apart from diabetic nephropathy. “Acceptable to use” and “benefits outweigh risks” indicate an option that can be used. “Risks outweigh benefits” indicate this option should be used with caution under specialist guidance and only if other methods are not available. (Copyright © 2016). Adapted from Faculty of Sexual and Reproductive Healthcare, Royal College of Obstetricians and Gynaecologists [Internet]. UK Medical Eligibility Criteria for Contraceptive Use; https://www.fsrh.org/documents/ukmec-2016/.¹⁰⁴.

Abbreviations: APLAS, antiphospholipid antibody syndrome; BP, blood pressure; CKD, chronic kidney disease; IUD, intrauterine device; OCP, oral contraceptive pill; RCOG, Royal College of Obstetricians and Gynaecologists; SLE, systemic lupus erythematosus.

National Kidney Foundation [Internet]NKF KDOQI Guidelines2002 Available from: http://www2.kidney.org/professionals/KDOQI/guidelines_ckd/p4_class_g1.htmAccessed October 4, 2015

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