Management of Chronic Kidney Disease with Worsening Azotemia in Pregnancy
Women with worsening azotemia during pregnancy should be managed by a multidisciplinary team in a tertiary center with close monitoring of renal function, blood pressure, and proteinuria to prevent permanent deterioration of kidney function and optimize maternal-fetal outcomes. 1
Risk Assessment and Monitoring
- Women with incipient renal failure (serum creatinine ≥3 mg/dl or creatinine clearance <50 ml/min) should be counseled that pregnancy may induce permanent worsening of renal function in 40% of patients 1
- Baseline assessment of renal function (serum creatinine and urinary protein excretion) should be performed before conception and followed at regular intervals throughout pregnancy 1
- Monitor blood pressure, kidney function, and proteinuria frequently during pregnancy, with more intensive monitoring for those with pre-existing hypertension 1
- Weekly home blood pressure monitoring is recommended, particularly in cases of pre-existing hypertension 1
Blood Pressure Management
- Target blood pressure should be 110-140/85 mmHg in pregnant women with CKD 1
- First-line antihypertensive medications during pregnancy include:
- ACE inhibitors and ARBs are contraindicated during pregnancy due to teratogenicity and should be discontinued prior to conception 1
Medication Management
- Review all medications for teratogenicity potential before conception and during pregnancy 1
- Consider GFR when dosing medications cleared by the kidneys 1
- Discontinue potentially teratogenic medications prior to pregnancy and do not restart until breastfeeding is completed 1
- Monitor therapeutic medication levels more frequently during pregnancy due to physiologic changes affecting drug clearance 1
Management of Worsening Azotemia
- For rapidly progressing CKD (stage 3 to stage 5) during pregnancy, consider protective hemodialysis starting as early as 28 weeks of gestation 2
- Early dialysis with an aggressive dialysis prescription of approximately 36 hours per week appears to convey the best outcome for those with progressive renal disease in pregnancy 1
- Diuretics should be used cautiously and only in combination with other drugs, particularly when vasodilators exacerbate fluid retention 1
Prevention of Complications
- Administer low-dose aspirin (150 mg in the evening) from the first trimester until 36 weeks gestation to reduce the risk of preeclampsia 1
- Screen regularly for preeclampsia, particularly in women with proteinuria >190 mg/day before or during early pregnancy 1
- Monitor for gestational diabetes, especially in women on glucocorticoid treatment 1
- Perform monthly urinalysis and treat asymptomatic bacteriuria with appropriate antibiotics to prevent pyelonephritis 1
Delivery Planning
- Timing of delivery should be determined based on maternal and fetal status, with consideration for preterm delivery if maternal condition worsens 1, 2
- Consider cesarean section in cases of worsening renal function, severe preeclampsia, or fetal distress 2
- Steroids should be administered 48 hours before delivery to accelerate lung maturation if gestation is <34 weeks 1
Postpartum Care
- Women with CKD should be seen by a nephrologist early (at 6 weeks) and within 6 months after delivery for a postpartum kidney function review 1
- Monitor for postpartum worsening of renal function, as pregnancy may have long-term effects on kidney disease progression 3
Special Considerations
- In women with severe CKD, pregnancy outcomes are generally worse, with higher rates of preeclampsia (22-29%), preterm birth (14-53%), and potential for permanent worsening of renal function 1, 3
- The live birth rate in women with chronic renal disease ranges between 64% and 98%, depending on the severity of renal insufficiency and presence of hypertension 3
By implementing these management strategies, healthcare providers can help optimize outcomes for both mother and baby in pregnancies complicated by CKD with worsening azotemia.