What are the key considerations for managing IgA (Immunoglobulin A) Nephropathy during pregnancy?

Key Considerations for Managing IgA Nephropathy During Pregnancy

Pregnancy in IgA nephropathy patients requires coordinated care between nephrology and obstetrics, with close monitoring for hypertension, proteinuria, and preeclampsia, as these complications occur at significantly higher rates even in patients with mild disease. 1

Pre-Pregnancy Assessment and Planning

• Optimal timing: Pregnancy should be planned when:

  • IgA nephropathy is inactive/stable for at least 6 months
  • Proteinuria is <0.5-0.75 g/day
  • eGFR is >50 ml/min/1.73m² (preferably higher)
  • Blood pressure is well-controlled 1, 2

• Medication adjustment:

  • Discontinue teratogenic medications (e.g., MMF, cyclophosphamide) at least 3-6 months before conception
  • Switch from ACE inhibitors/ARBs to pregnancy-safe antihypertensives before conception or as soon as pregnancy is confirmed
  • Continue hydroxychloroquine if already prescribed (safe during pregnancy) 1

Monitoring During Pregnancy

First Trimester

• Baseline assessment:

  • Kidney function (serum creatinine, eGFR)
  • Proteinuria quantification (24-hour collection or UPCR)
  • Blood pressure (including home measurements)
  • Urinalysis for hematuria 1

• Start low-dose aspirin (81-100mg daily) before 16 weeks gestation to reduce preeclampsia risk 1

Throughout Pregnancy (Every 2-4 Weeks)

• Monitor:
  • Blood pressure (target <130/80 mmHg)
  • Proteinuria (expect potential worsening)
  • Kidney function
  • Complete blood count
  • Urinalysis 1, 3

Managing Common Complications

Hypertension

• Extremely common: Studies show 100% of IgA nephropathy patients may develop hypertension during pregnancy, even with normal pre-pregnancy blood pressure 3
• Management:
  • Preferred agents: Labetalol, nifedipine, methyldopa
  • Target BP <130/80 mmHg
  • Avoid ACE inhibitors/ARBs during pregnancy 1, 2

Worsening Proteinuria

• Expected progression: Proteinuria typically increases during pregnancy in IgA nephropathy patients
• Studies show average increases from ~500 mg/day pre-pregnancy to >2000 mg/day in third trimester 3
• Management:
  • Close monitoring
  • Salt restriction (<2.0 g/day)
  • Optimize blood pressure control 1

Preeclampsia

• High risk: 25% of IgA nephropathy patients may develop preeclampsia 3
• Prevention: Low-dose aspirin started before 16 weeks gestation
• Monitoring: Regular BP checks, proteinuria assessment, and screening for preeclampsia symptoms
• Management: Multidisciplinary approach with nephrology and high-risk obstetrics 1

Effect on Long-Term Renal Prognosis

• Most women with well-controlled IgA nephropathy (normal BP, GFR >70 ml/min) can expect successful pregnancies without long-term impact on disease progression 4, 5
• Risk factors for accelerated disease progression:
  • Pre-pregnancy serum creatinine >2.0 mg/dL
  • Uncontrolled hypertension
  • Significant proteinuria (>1 g/day) before conception 6, 4

Post-Partum Considerations

• Close monitoring: Kidney function may temporarily worsen immediately post-partum, especially in patients with pre-existing proteinuria 7
• Resume appropriate medications for IgA nephropathy management
• Reassess disease status 1-3 months post-delivery 1

Common Pitfalls to Avoid

1. Failure to plan pregnancy: Pregnancy should be planned when disease is stable and medications adjusted accordingly
2. Inadequate BP monitoring: Even patients with normal pre-pregnancy BP commonly develop hypertension
3. Missing preeclampsia: Distinguishing between worsening IgA nephropathy and preeclampsia can be challenging
4. Medication errors: Continuing teratogenic medications or failing to start low-dose aspirin
5. Insufficient monitoring frequency: Pregnancy with IgA nephropathy requires more frequent monitoring than uncomplicated pregnancies

By following these guidelines and maintaining close coordination between nephrology and obstetrics, most women with stable IgA nephropathy can have successful pregnancies while minimizing risks to maternal kidney function and fetal outcomes.