Studies

Renal disease in pregnancy

Background

Pregnancy in women with advanced kidney disease, a functioning kidney transplant or receiving dialysis, poses a challenging clinical scenario, fraught with high maternal-fetal morbidity and threat to maternal renal health. This prospective study using AMOSS will assess significant kidney disease in Australian and New Zealand pregnant women to define the epidemiology, risk factors and consequences; evaluate management practices and gaps; and provide evidence to improve counselling and care to affected women. 

Chronic kidney disease (CKD) in pregnancy

... is a major health problem in Australia. It is often found in association with diabetes and cardiovascular disease and disproportionately burdens Indigenous populations (1, 2). CKD may be diagnosed pre-conception or present in pregnancy. Previous studies estimate Stage 3-5 CKD affects 0.1 % of pregnancies (3). The prevalence of CKD in ANZ mothers is unknown, but is likely influenced by the rise in diabetes, obesity and older mothers (4).

Maternal CKD and Pregnancy Outcomes:

Any maternal CKD increases risks of obstetric morbidity, especially hypertension, pre-eclampsia, fetal loss, prematurity, growth retardation, and perinatal problems (5-7). Women with low pre-conception kidney function, especially those receiving dialysis, have the poorest outcomes, and accelerated deterioration in renal function may necessitate dialysis during pregnancy. Even after successful transplantation, these pregnancies remain high risk (8, 9). 

Parenthood is a central focus for women with CKD but raises important fears and uncertainties about risks to their own and their baby’s health (10, 11). Complex, shared decision-making relies on accurate data about these risks.

Acute kidney injury (AKI) in pregnancy

AKI is a rare, potentially catastrophic event in pregnancy, caused predominantly (in developed countries) by pre-eclampsia. Approximately 1/10,000 pregnant women require acute dialysis, and poorer perinatal outcomes and higher maternal death rates are observed (12). There are no ANZ data regarding pregnancy-related AKI.  

CKD and AKI in pregnancy, while uncommon, causes a high burden of maternal- and -perinatal morbidity.

Our challenge is provision of evidence-based recommendations for clinicians, with rigorous specialised antenatal care to optimise pregnancy and birth outcomes. This model of care may not be equitably available to higher-risk women: particularly those who are Indigenous, geographically isolated or lower SES. Poor information regarding maternal kidney disease in ANZ presently limits our ability to counsel and treat these women. 

Aims

For women in Australia with advanced chronic kidney disease (CKD; Stage 3b-5 including dialysis and transplant recipients) and Acute Kidney Injury (AKI) in pregnancy:

1.     Determine the prevalence, distribution and characteristics of maternal renal disease, with focus on at-risk groups including Indigenous women.

2.     Describe pregnancy management; evaluate patterns of presentation, resource utilisation, models of care and adequacy of health care delivery.

3.     Examine relationships between maternal renal disease and adverse maternal obstetric and renal outcomes, perinatal morbidity, and mortality.

Methods

A prospective study of Stage 3b-5 CKD (including dialysis and transplant recipients) and AKI in pregnancy across Australia/NZ, using the Australasian Maternity Outcomes Surveillance System (AMOSS). The study will have 2 stages – an initial observational study (Year 1) to determine prevalence and obtain preliminary outcomes data for subsequent Case-control Study (Year 2).

Study period

Surveillance and observational study August 2017- July 2017 

Researchers

Dr Shilpa Jesudason, Nephrologist, Central and Northern Adelaide Renal and Transplantation Service (CNARTS); Consultant, Women's and Children's Hospital Adelaide, South Australia

Professor Elizabeth Sullivan, Principal Investigator AMOSS, Professor of Public Health, Assistant Deputy Vice Chancellor, University of Technology Sydney and Conjoint Professor, UNSW Medicine, New South Wales

Professor Stephen McDonald, Nephrologist, CNARTS; Executive Officer, ANZDATA Registry

Professor William Hague, AMOSS Site Investigator/Obstetric Physician, Women's and Childrens Hospital Adelaide, South Australia

References

1.    Australian Institute of Health and Welfare.  2014. Cardiovascular disease, diabetes and chronic kidney disease-Australian facts: Prevalence and incidence. Cardiovascular, diabetes and chronic kidney disease series no. 2.Cat. no. CDK 2. Canberra: AIHW.
2.    ANZDATA Registry. 37th Report. Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia. 2015. Available at: http://www.anzdata.org.au.
3.    Munkhaugen J, Lydersen S, Romundstad PR, Wideroe TE, Vikse BE, Hallan S. Kidney function and future risk for adverse pregnancy outcomes: a population-based study from HUNT II, Norway. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2009;24(12):3744-50.
4.    Hilder L, Zhichao Z, Parker M, Jahan S, Chambers GM 2014. Australia’s mothers and babies 2012. Perinatal statistics series no. 30. Cat. no. PER 69. Canberra: AIHW.
5.    Nevis IF, Reitsma A, Dominic A, McDonald S, Thabane L, Akl EA, et al. Pregnancy outcomes in women with chronic kidney disease: a systematic review. Clinical journal of the American Society of Nephrology : CJASN. 2011;6(11):2587-98. Epub 2011/09/24.
6.    Piccoli GB, Cabiddu G, Attini R, Vigotti FN, Maxia S, Lepori N, et al. Risk of Adverse Pregnancy Outcomes in Women with CKD. Journal of the American Society of Nephrology : JASN. 2015;26(8):2011-22. Epub 2015/03/15.
7.    Jesudason S, Grace BS, McDonald SP. Pregnancy outcomes according to dialysis commencing before or after conception in women with ESRD. Clinical journal of the American Society of Nephrology : CJASN. 2014;9(1):143-9.
8.    Wyld ML, Clayton PA, Jesudason S, Chadban SJ, Alexander SI. Pregnancy outcomes for kidney transplant recipients. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons. 2013;13(12):3173-82. Epub 2013/11/26.
9.    Levidiotis V, Chang S, McDonald S. Pregnancy and maternal outcomes among kidney transplant recipients. J Am Soc Nephrol. 2009;20(11):2433-40. Epub 2009/10/03.
10.    Tong A, Jesudason S, Craig JC, Winkelmayer WC. Perspectives on pregnancy in women with chronic kidney disease: systematic review of qualitative studies. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association. 2015;30(4):652-61. Epub 2014/12/20.
11.    Tong A, Brown MA, Craig JC, Winkelmayer WC, Jesudason S. Perspectives on pregnancy in women with CKD: a semi-structured interview study. American Journal of Kidney Disease 2015;66(6): 951-961. 
12.    Hildebrand AM, Liu K, Shariff SZ, Ray JG, Sontrop JM, Clark WF, et al. Characteristics and Outcomes of AKI Treated with Dialysis during Pregnancy and the Postpartum Period. Journal of the American Society of Nephrology : JASN. 2015.