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Review

Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases

1
Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy
2
Néphrologie, Centre Hospitalier Le Mans, 72000 Le Mans, France
3
Nephrology, Moscow City Hospital n.a. S.P. Botkin, 101000 Moscow, Russia
4
Nephrology, Moscow State University of Medicine and Dentistry, 101000 Moscow, Russia
5
Nephrology, Russian Medical Academy of Continuous Professional Education, 101000 Moscow, Russia
6
Obstetrics, Department of Surgery, University of Torino, 10100 Torino, Italy
7
Nephrology Service, Hospital Civil de Guadalajara “Fray Antonio Alcalde”, University of Guadalajara Health Sciences Center, Guadalajara, Jal 44100, Mexico
8
Instituto Nacional de Perinatologia, Mexico D.F. 01020, Mexico
9
Department of Medicine, Dubai Medical College, P.O. Box 20170, Dubai, UAE
10
National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing 210000, China
11
Yaounde General Hospital & Faculty of Medicine and Biomedical Sciences, University of Yaounde I, P.O. Box 337, Yaounde, Cameroon
12
Nefrologia Ospedale Brotzu, 09100 Cagliari, Italy
13
Prince of Wales Hospital, Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong
14
Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
*
Author to whom correspondence should be addressed.
J. Clin. Med. 2018, 7(11), 415; https://doi.org/10.3390/jcm7110415
Submission received: 7 October 2018 / Revised: 28 October 2018 / Accepted: 31 October 2018 / Published: 5 November 2018

Abstract

:
Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women.

1. Introduction

Chronic kidney disease (CKD) is a well-acknowledged risk factor for adverse pregnancy outcomes [1,2,3,4,5,6,7]. The literature on this issue is rapidly accumulating and the term “obstetric nephrology” has been proposed to identify this important clinical and research field [8].
However, awareness of the importance of identifying CKD in pregnancy is still insufficient and the experience is mainly limited to some large, but still few, referral centers [3,9,10,11,12].
This narrative review, in association with a review on pregnancy and acute kidney injury (p-AKI), has been based on the theme of the World Kidney Day 2018, which highlighted women’s health and kidney disease [13]. Importantly, the focus of this narrative is on what could be done to improve CKD care throughout and after pregnancy.
The review follows the classic, even if not necessarily sequential, phases of renal diseases: chronic kidney disease, dialysis, and transplantation, and focuses on the knowledge gaps, on the delay of application of what is known into the clinical practice, and on the potential interventions that could improve the care of mother and child during and after pregnancy.

2. Chronic Kidney Disease

2.1. State of the Art: What We Know on the CKD-Pregnancy Relationship: CKD Stages

Kidney function is of crucial importance in healthy pregnancy [8].
Several changes in kidney function occur in the pregnant woman, affecting the vascular, glomerular, and tubular components, ultimately resulting in increased renal clearances and “physiological” proteinuria, decrease in blood pressure, and expansion of the intravascular volume [8,14,15,16,17].
The kidney is the target and the central player in the hypertensive disorders of pregnancy, an umbrella term that gathers the most common pregnancy-induced disorders: isolated hypertension (usually identified by the acronym PIH: pregnancy induced hypertension), pre-eclampsia (PE), in which hypertension is usually associated with proteinuria and may be associated with acute and transient reduction of the kidney function (now considered a hallmark of the PE syndrome, even in the absence of proteinuria), HELLP syndrome, an acronym for haemolysis, elevated liver enzymes, low platelets, a severe, occasionally life-threatening, endothelial disorder [8,14,15,16,17,18,19,20]. Isolated proteinuria may also transiently appear in pregnancy and is usually indicated as “pregnancy-induced proteinuria”. Proteinuria may precede PE, but even when isolated, it heralds a risk of adverse pregnancy outcomes, including growth restriction and preterm delivery; the differential diagnosis between pregnancy-induced and pre-existent proteinuria may not be easy [20,21,22,23].
Due to the central role of the kidney, target, and actor in the pathogenesis of the hypertensive disorders of pregnancy, it is not surprising that a reduction of the kidney function may affect pregnancy outcomes [1,2,3,4,5,6,7,8,9,24]. What may be surprising is that kidney diseases are associated with a significant increase in the risk of adverse pregnancy outcomes even in the absence of kidney function reduction [4,5,25,26,27,28,29,30].
In this regard, interesting insights come from the analysis of pregnancy after kidney donation, which shows that this condition of “healthy” reduction of the kidney parenchyma is associated with a higher risk of pre-eclampsia and hypertensive disorders of pregnancy [25,26,31,32,33].
Overall, the risks of adverse pregnancy outcomes increase from CKD stage 1 to CKD stage 5, and are further increased in diabetic nephropathy and in systemic autoimmune diseases, such as systemic lupus erythematosus (SLE) [1,2,3,4,5,6,7,8,9,34,35,36,37,38,39,40].
In each CKD stage, hypertension and proteinuria are important modulators of the entity of pregnancy-related risks; however, the specific role of each element (kidney disease, stage, hypertension, and proteinuria) is not fully known, thus limiting the information available for counseling [41,42,43,44] (Table 1). Furthermore, perinatal outcomes depend also upon the setting of care, an issue that has to be taken into account both in interpreting results and in planning treatment strategies.
As it will be further discussed, our knowledge on the specific risks linked with the different kidney diseases is limited; overall, we know more about glomerular diseases, and the most common ones, such as IgA nephropathy, are extensively studied; conversely, the specific risks associated with interstitial nephropathies or polycystic kidney disease (ADPKD) are not fully appreciated [7,9,45,46,47,48,49,50,51].
Table 2 resumes the main pregnancy-related risks in CKD patients: overall, malformations are not increased with respect to the overall population (out of the context of inherited diseases and of diabetic nephropathy); maternal death is exceptional, at least in highly resourced countries.
Conversely, the incidence of preterm delivery and of small babies (Figure 1) is increased already in stage 1 CKD, with respect to the overall population, and rises along with the increase of CKD stages [1,2,3,4,5,6,7,24,27,28]. Likewise, the effect of pregnancy on CKD progression is debated, also on account of the different study designs, obstetric policies, and duration of follow-up of CKD women after pregnancy. Overall, short- and long-term decrease in the kidney function is exceptional in the first CKD stages, but rapid decrease of the kidney function may be an issue in late CKD stages [1,2,3,4,5,6,7].
Once more, studies are heterogeneous and evidence is limited; as a consequence, entity of the risk of CKD progression has been variously estimated (Table 2).
The information on the outcomes of pregnancy in the last CKD phases is still scant. Fertility is usually reported as reduced in the last CKD stages, but it is possible that the attitude of discouraging pregnancy in advanced CKD has induced a selection bias [52,53].

2.2. A Particular Case: Systemic Immunologic Diseases

Kidney disease in SLE is a critical concern for pregnancy. Kidney involvement includes lupus nephritis (LN), characterized by glomerular damage and interstitial and vascular lesions. Beyond risk factors associated with CKD (proteinuria, hypertension, and impaired kidney function, Table 1 and Table 2), SLE is associated with a specific increase in miscarriages and perinatal death. All risks are higher in active SLE, and adverse outcomes are associated in particular with LN class 3 and 4, history of renal flares, longer disease, hypocomplementemia, presence of antiphospholipid antibodies (aPL), and antiphospholipid syndrome (APS) [5,6,7,54,55].
Conversely, pregnancy carries a risk of SLE flares: high estrogen level may act as triggers, by mediating transcription activity of the intracellular estrogen receptors and interacting with regulatory T cells, key modulators of maternal–foetal tolerance [56]. Upregulation of IFN-α may also play a role in SLE and LN: this cytokine, highly expressed by the placenta, contributes to placentation and increases susceptibility to SLE [57,58,59]. Low C3 and high anti-DNA antibodies predict renal flares, whereas high anti-C1q antibodies and low C4 predict early flares.
Pregnancy complications, along with vascular thrombosis, are the main clinical criteria for antiphospholipid syndrome, which may be isolated (primary forms) or associated to SLE or other autoimmune disorders. The disease directly affects placental vasculature, ultimately resulting in placental dysfunction: antiphospholipid antibodies affect the cytotrophoblast via thrombosis, inflammation, apoptosis, and immunomodulatory impairment; direct damage of endometrial cells has also been described [60,61]. APS-related complications in pregnancy include the whole list of pregnancy complications: recurrent miscarriage, preterm delivery, IUGR, stillbirth, fetal distress, fetal or neonatal thrombosis, PE, eclampsia, HELLP syndrome, arterial or venous thrombosis, and placental insufficiency. High titers and triple positivity for aPL (usually defined as positivity for LLAC and for anti-cardiolipin (aCL) and anti-β2GPI antibodies of the same isotype by the same method) are associated with mother and foetal complications, including miscarriage [60,61,62,63,64,65,66,67,68,69]. A particularly severe syndrome, named catastrophic APS (CAPS), combines all these damages into multiorgan failure [60,61,62,63,64,65,66,67,68]. The occurrence of HELLP syndrome in a patient with APS should raise the suspicion of CAPS, and defines a permanent risk for further pregnancies [69].
The link between pregnancy-induced thrombocytopenia or endothelial damage and other causes, including thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS), now often referred to as thrombotic microangiopathies (TMA), is not fully clear; the diseases may overlap and the differential diagnosis may become evident only after pregnancy (Table 3) [70].
Among other common autoimmune diseases, rheumatoid arthritis (RA) mostly affects women of perimenopausal age; however, its incidence is non-negligible in younger patients (8.7 per 100,000 per year at age 18–34 and 36.2 per 100,000 at age 35–44). CKD in RA may result from RA-associated glomerulonephritis, chronic inflammation, comorbidities, nephrotoxic antirheumatic drugs, and amyloidosis [71,72,73,74,75,76,77,78]. Specific pregnancy risks linked to RA are not clearly defined, even if an increase in preterm delivery and low birth weight has been reported (Table 1 and Table 2). Interestingly, RA patients may experience remission during pregnancy, presumably due to changes in sex hormones profiles [75,76,77,78,79,80]. Similar considerations may apply to systemic sclerosis (SS), a severe immunologic disease mostly affecting women of postmenopausal age, but present also in a younger population, where it carries a risk for prematurity and IUGR and SGA babies. Conversely, SS flares are rare but may be life-threatening in pregnancy [81,82,83,84].

2.3. What is Missing, and What We Still Need to Know

Indirect estimates of the prevalence of CKD in pregnancy come from the assumption that fertility is not affected in early CKD and that the prevalence of early kidney disease is the same as in the overall population [1,85]. Based upon this assumption, it has been suggested that early-stage CKD is present in 3:100 pregnancies and later-stage CKD in 1:750 pregnancies [1,85]. Interestingly, the reported prevalence of CKD is strikingly similar to that of PE, much better acknowledged as an important risk in pregnancy [1,85,86]. Furthermore, the estimation of the prevalence of CKD in pregnancy, in the classic paper by Williams and Davison, is based upon an evaluation performed in western, highly resourced countries, and may be underestimated in medium- and low-income countries, in which the prevalence of CKD is usually higher [1,85,86,87,88,89,90,91]
Assessing the actual prevalence of CKD in pregnancy should therefore be a health care priority, also since pregnancy may represent an underutilised, but highly valuable, occasion for the diagnosis of CKD, in particular in disadvantaged populations in which the opportunities for early CKD diagnosis are few [90,91,92,93,94]. In fact, pregnancy is often the first occasion in which an apparently healthy woman undergoes a clinical and laboratory evaluation, which has the potential to timely reveal the presence of underlying CKD. However, the only assessment systematically done and regarding the kidney is the urinalysis, which is usually interpreted only with regard to the presence of proteinuria, or of urinary tract infection [95,96,97].
Simple and inexpensive measures, such as including the assessment of serum creatinine in the routine pregnancy tests, could improve early diagnosis of kidney diseases, in particular if the physiological decrease of serum creatinine levels, due to physiological changes in pregnancy, is acknowledged. In this regard, there is also a need to determine reference values for creatinine during pregnancy, by race and pregnancy trimester. Addition of serum creatinine will not solve all problems, but may allow identifying at least cases with kidney function impairment. Indeed, many kidney diseases are fully asymptomatic; not all kidney diseases manifest with hypertension and proteinuria, the symptoms on which attention is more focused; haematuria or electrolyte derangements may be overlooked in pregnancy and there is a consistent overlap of signs and symptoms between PE and CKD in pregnancy [98,99,100,101]. These diagnostic challenges are summarised in Table 4.
Furthermore, signs and symptoms of CKD and PE may overlap, and there is a need for establishing common lines for systematically considering the differential diagnosis between CKD and PE in pregnancy; while a combination of Doppler flows and the biomarkers employed in the assessment of PE may support diagnosis, large prospective studies are needed to refine the procedures and validate their use [101,102,103].

3. Dialysis

3.1. The State of the Art

Fertility is reduced in end-stage kidney disease; Australian and European data suggest that pregnancy occurs ten times less frequently in patients with kidney transplantation than in the general population and that pregnancy occurs ten times less frequently in dialysis patients compared with kidney transplant patients. In other words, a woman on dialysis has a probability of having a baby that is 1% of the overall population [104,105,106].
While the first sporadic cases of successful pregnancy on dialysis were described in the seventies, it was only in the new millennium that pregnancy on dialysis became an acknowledged clinical possibility [104,105,106,107,108,109,110]. So far, more than 1000 pregnancies have been reported in dialysis patients, with an increasing trend worldwide [109].
The most important advance in this field has been the demonstration of a strict relationship between the intensity (frequency and duration) of the dialysis sessions and pregnancy results, thus leading to intensify dialysis up to daily, favoring also long-hours treatment as compared to standard schedules [107,108,109,110].
The improvement in results recorded with daily, extended-hours dialysis not only allowed a more permissive attitude towards pregnancy in dialysis, but is also leading to a more positive attitude towards pregnancy in advanced CKD, often previously discouraged for the fear of needing to start dialysis during gestation [107,108,109,110,111,112,113,114].
While the “best” (if any) dialysis prescription is still not agreed upon, some common lines are emerging, specifically from the Canadian experience: in patients without residual renal function, at least 36 h of dialysis per week should be prescribed, and daily frequency should be chosen; weight loss during the session should be very slow, hypotension should be avoided, and hypertension not hypercorrected; heparin anticoagulation is safe (more experience with unfractioned heparin); biocompatible membranes should be used; multivitamin supplementation and high-protein diets should be prescribed to compensate for intradialytic nutrient loss; phosphate supplements may also be needed. Low blood and dialysate flows should allow a “soft” dialysis; Kt/V is not the ideal marker of dialysis efficiency and the target is set at “near normal” predialysis urea (after the day break) (Table 4) [10,109,111].
In settings where dialysis is available without restrictions, pregnancy in dialysis is becoming more common, though still a rare occurrence, underlining the importance of a network of care for sharing opinions, gathering data, and optimizing results [110,114].
Conversely, in poorly resourced countries, pregnancy is a common precipitating event of severe CKD, often not previously diagnosed; furthermore, in these settings, p-AKI is more common and may not be reversible in 5–30% of the cases, further underlining the complex link between PE, p-AKI, and CKD in pregnancy [115,116,117,118].

3.2. What Is Missing and Could Be Done in the Clinical Practice

The evidence on pregnancy and dialysis is heterogeneous and several questions are still unanswered. Two of them are of pivotal importance: when to start dialysis in pregnancy and how we can mediate between the excellent results obtained by Hladunewich in Canada with long-hours daily dialysis and the limited access to dialysis in many developing countries.
The issue of dialysis start in pregnancy is complex; the Canadian data, which indicate that a target of predialysis “near normal” urea level is associated with better outcomes, are often taken as an indication to start dialysis early. While this attitude may be reasonable, it has not been proven, and is not in keeping with the recent indications to start dialysis within an “intent to delay” policy in all other categories of patients [111,119,120,121,122].
As a consequence of this uncertainty, the residual kidney function at dialysis start in pregnancy ranges from 20 mL/min, a level that would not have supported the indication to start RRT outside of pregnancy, to the usual levels of less than 10 mL/min [123,124].
There are very few position statements from scientific societies on these issues; the most recent Italian one leaves the question open, advocating an individualised approach [6,111]. Furthermore, the role of nutritional support to delay dialysis start in pregnancy has been insufficiently studied, and the promising results obtained with plant-based diets need large-scale validation [125,126,127]. There is an urgent need for gathering and exchanging data on this crucial issue to ensure the best timing of start of dialysis in pregnancy, in the interest of the mothers and the babies.
The second issue, regarding the difficulty in implementing the long, daily dialysis schedules, is also open; this is of utmost importance in developing countries, such as Mexico, where intensive dialysis may lead to a competition for a lifesaving treatment [92]. Shorter dialysis schedules and peritoneal dialysis are reported as alternatives, but publication bias is an important limit to assess the real equivalence of these more easily manageable treatments [128,129,130,131,132]
Low income should not become synonymous with low quality, and data coming from medium–low-income countries show that very good results can be obtained in all settings; the populations may, however, be different, as well as the kidney diseases. There is a need for establishing a common language, allowing exchanging on dialysis approaches and detailed results to allow tailoring dialysis to patients, considering also the available resources. Some open questions regarding the management of the dialysis schedules are summarized in Table 5.

4. Kidney Transplantation

Fertility is at least partly restored after kidney transplantation, and the possibility to undertake a successful pregnancy is usually considered an added value of a functioning kidney graft. Reports on pregnancies after kidney transplantation rapidly followed the development of kidney transplant programs and thousands of pregnancies have now been reported all over the world [133,134,135,136,137,138,139,140].
However, even in an ideal situation, the risk of complications is higher than in the general population and was recently described as corresponding to stage-1 CKD in native kidneys, in patients with potentially progressive CKD [140,141]. If teratogen drugs are avoided (Appendix Table A1, Table A2, Table A3 and Table A4), pregnancy after kidney transplantation shares the same risk factors with CKD pregnancies, suggesting that kidney function, hypertension, and proteinuria matter more than treatments [141]. Indeed, the reduced nephron mass of a solitary transplanted kidney may not be resilient enough to the stressors of hyperfiltration of pregnancy, even in the presence of normal kidney function.
The profile of the “ideal” candidate for pregnancy after transplantation is well defined: a young, nonobese, normotensive woman, with normal kidney function, in the absence of proteinuria, without any rejection episode, or at least any recent rejection episode, with good compliance, and at least two years from transplantation [133,134,140,141,142,143,144]. However, a univocal definition of age, kidney function, and interval after the last rejection episode is missing, and the grading of the risks is not clear, in particular in women with signs of kidney function impairment. This “ideal” situation is indeed not always the rule, in particular in deceased donor transplantation. In fact, expanded donor policies may lead to suboptimal kidney function; higher age at transplantation and reduced fertility are not infrequent; conversely, the good results of pregnancy after kidney transplantation are somehow smoothing the contraindications, with a widespread agreement on a shorter stabilization time, and a permissive attitude towards pregnancy with less-than-optimal kidney function [133,134,135,136,137,138,139,140,141,142,143,144].
The literature is rich with reports on extreme situations, including kidney transplantation during pregnancy; while single cases cannot lead to potentially risky changes in daily practices, such cases do warn against fully negative attitudes and suggest an individually based decision [145,146,147,148,149,150,151].
In particular in western countries, where age of the transplant recipients is often older, assisted fertilization is increasingly popular. Besides the ethical challenges, whose discussion is beyond the scope of this review, assisted fertilization techniques, in particular those in vitro, are associated with an increase of pregnancy complications and of hypertensive disorders of pregnancy, with a potential negative effect on the kidney function [152,153,154,155,156]. The scattered data on assisted fertilization in kidney transplant recipients are, however, encouraging; once more, the series are very small, most of them regarding single cases, and, in such a context, it is highly probable that reports are influenced by a publication bias [152,153,154,155,156].

What Is Missing and Could Be Done in the Clinical Practice

Most of the available data on kidney transplantation regard pregnancies in ideal or “almost ideal” clinical conditions; there is very little evidence available on pregnancy in patients with reduced kidney function. In these cases, in which counseling is particularly important, the data we now have are scant and we can rely only on personal experience or indirect evidence.
There is a need for gathering data on these situations, to improve counseling and to increase awareness of the challenges of pregnancy in patients with a failing graft.
Pregnancy represents an immunologic challenge and is a potential cause of hyperimmunization, a well-known problem for transplantation. Living unrelated grafts increasingly offer a clinical solution within couples: the eventual role of pregnancy as an immunologic trigger leading to rejection of the grafted kidney should be clarified to optimize the outcomes of transplantation between husband and wife [142].
Not least, long-term data on children born from a transplanted mother are still lacking, and attention should be focused on this important issue [157].

5. Conclusions

Pregnancy is now possible in all phases of chronic kidney disease, but its management may be difficult and the outcomes are not the same as in the overall population.
There is a lot to do to improve pregnancy outcomes in CKD, whose prevalence in pregnancy is probably as high as that of PE, a better-acknowledged risk for adverse outcomes. When CKD is known, pregnancy should be considered as at high risk and followed accordingly, since the earliest stages. Furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy and timely treatment after pregnancy. The differential diagnosis between CKD and pre-eclampsia may be difficult but is important for pregnancy management.
Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive, long-hours, quotidian dialysis is the choice allowing the best results; these indications have, however, to be adapted to poorly resourced countries, where daily dialysis may not be feasible for clinical, economical, or logistic issues.
After kidney transplantation, pregnancies should be followed up with great attention to minimize the risks for mother, child, and for graft.
Specialized and committed teams are crucial for optimizing the care of pregnant CKD patients, and efforts should be done to organise such teams.
The advances in our knowledge are strictly linked to the progress in research, and international comparisons are highly needed to ameliorate our understanding and to define treatment strategies. The research agenda is long, from epidemiology of CKD to differential diagnosis between CKD and PE, evaluation of target blood pressure in CKD pregnancies, or the role of the nutritional follow-up. Furthermore, dialysis start, dialysis policy, and modulation of posttransplant therapies should be discussed on a global basis, to identify the best context-sensible policies to allow more CKD women to attain successful pregnancy.

Author Contributions

Conceptualization, G.B.P., A.L., E.Z., R.A., M.I.-H., B.C., M.A., L.Z.-H., G.A., A.O.G.; Writing-Original Draft Preparation, G.B., R.A., G.C.; Writing-Review & Editing, G.B.P., A.L., E.Z., R.A., M.I.-H., B.C., M.A., L.Z.-H., G.A., A.O.G.; Supervision, G.C., P.K.T.L., G.G.-G.

Funding

This research received no external funding.

Acknowledgments

To Susan Finnel for her careful language editing.

Conflicts of Interest

The authors declare no conflicts of interest.

Appendix A

Table A1. Main immunosuppressive drugs for CKD patients in pregnancy.
Table A1. Main immunosuppressive drugs for CKD patients in pregnancy.
DrugMain FeaturesFDA
Usually considered as relatively safe, when absolutely needed
Azathioprine (AZA)It is teratogenic in animal models, at high doses, but not in humans, possibly because the foetal liver is not able to activate the drug. KDIGO and European Best Practice Guidelines suggest switch from Mycophenolate to AZA before pregnancy.D
Cyclosporine A (CyA)Hypertension, hyperglycaemia and nephrotoxicity may be relevant in pregnancy. CyA has not been associated with teratogenicity; SGA babies and preterm delivery have been reported, with an unclear link with maternal disease; levels vary in pregnancy and need strict monitoring. C
TacrolimusThe drug has similar effects and side effects as CyA; the experience is more limited than with CyA.C
SteroidsThe most frequently used short-acting corticosteroids are prednisone, methylprednisolone and prednisolone; among long-acting betamethasone and desamethasone. No major malformation reported, increase of labio-palatoschisis is debated. A risk of premature rupture of membranes has been reported, along with increased risk of infection and gestational diabetes.C prednisone
HydroxychloroquineThis synthetic antimalaric agent crosses the placenta but was not associated with foetal toxicity.B
IV Immunoglobulin (IV Ig)IV Ig is indicated in SLE pregnant patients with recurrent spontaneous abortion. Safety has not been fully established.C
RituximabAnimal studies have shown adverse effects on the fetus; no adequate studies in humans. Benefit may warrant use in highly selected cases.C
BelimumabIn exceptional cases. No adequate studies in humans. Benefit may warrant use despite potential risks, in highly selected cases.C
To be avoided
CyclophosphamideReports suggest that pregnancy termination is common in case of inadvertent use. A few positive reports, mainly in SLE are available.D
MethotrexateAlso employed for extrauterine pregnancy termination. Discontinuation for one–three menstrual cycles pre-conception is usually indicated.X
Mycophenolate Severe foetal malformations are reported, mainly cardiovascular and cranial. Discontinuation for at lest 6 months, also for stabilizing the kidney function, is usually indicted after kidney transplantation.D
m-Tor inhibitors Very few studies regard their use in pregnancy. They are teratogenic in animals; discontinuation in humans is matter of debate; KDIGO guidelines suggest discontinuation in prevision of pregnancy. C
ThymoglobulinAnimal studies are not available.
There are no controlled data in human pregnancy.
NA
BasiliximabAnimal studies failed to reveal embryotoxicity, or teratogenicity. IgG are cross the placental barrier and the IL-2 receptor plays an important role in development of the immune system. There are no controlled data in human pregnancy. B
AlemtuzumabIn animal studies no teratogenic effects are observed. However, there was an increase in embryolethality in pregnant animals. There are no controlled data in human pregnancy, but potential benefits may warrant use of the drug in selected pregnant women despite potential risks.C
FDA site of the Food and Drug Administration; FDA rating: B. No evidence of risk in studies; C. Risk cannot be ruled out; D. Positive evidence of risk; X. Contraindicated in pregnancy. NA. not available.
Table A2. Main anti-hypertensive drugs for CKD patients in pregnancy.
Table A2. Main anti-hypertensive drugs for CKD patients in pregnancy.
DrugMain FeaturesFDA
Usually considered as first choice
Alpha-methyldopaWidely used in pregnancy, with no reported negative effects. May not be sufficient to correct severe hypertension in CKD.B
Niphedipine The long acting form is commonly used. In CKD the side effect of increasing peripheral oedema may be relevant. C
LabetalolUsually well tolerated, should be avoided in asthma. In a RCT it was comparable to alpha-methyldopa. C
Usually considered as second choices
Beta-blockersThe main negative effect in older studies was foetal growth restriction, possibly as an effect of overzealous correction of BP. Beta1 selective beta-blockers (atenolol) are more often in cause. May be more effective than alpha-methyldopa, alone or in combined therapy. At delivery they may induce hypoglycaemia, hypotension and bradycardia (usually mild and transient). D atenolol
B pindolol
C metoprol
ClonidineThe effect is similar to alpha-methyldopa; side effects may be more common and hypertensive rebounds at discontinuation are common; slowing fetal growth is occasionally reported. C
DiureticsThey are usually avoided in pregnancy except for cardiological indications. Thiazides may be continued in patients previously on treatment. In Gitelman syndrome, аmiloride may be needed. B hydrocloro-thiazide
To be avoided
Niphedipine short actingContraindicated by FDA, RCOG and AIPE for the risk of severe sudden hypotension with detrimental effect on placental flows.X
ACE-i/ARBs and related drugsBoth are contraindicated in all phases of pregnancy; different malformations, involging cardiovascular, central nervous system, renal and bone are reported. Recent studies suggest that the risk is limited to the second and third trimester. X
FDA site of the Food and Drug Administration; FDA rating: B. No evidence of risk in studies; C. Risk cannot be ruled out; D. Positive evidence of risk; X. Contraindicated in pregnancy. RCT: randomized controlled trial. RCOG: Royal College of Obstetricians and Gynecologists. AIPE—Italian Association on Preeclampsia.
Table A3. Main antibiotics for CKD patients in pregnancy.
Table A3. Main antibiotics for CKD patients in pregnancy.
DrugMain FeaturesFDA
Usually considered as first or second choices
Ampi-amoxycillinAmpicillin and Amoxicillin are the first-choice antibiotics. B
Clavulanic acidIndicated when therapy with the previous ones is not effective, or according to antibiogramme.B
CephalosporinsAvailable data do not indicate an increase of malformations; risk for kernicterus is increased (mainly ceftriaxone).B
CarbapenemsMeropenem is the first choice in severe infection; no demonstrated risks in humans; increased risk of malformations with imipenem-cilastatin in animals. B
AztreonamAlternative in case of allergy to beta-lactams (parenteral only).B
MacrolidesEritromicine is a good alternative in case of contraindication to beta-lactamics. Claritromicine and azitromicine are a second choice.B
PhosphomycinIndicated in uncomplicated urinary tract-infections. B
NitrofurantoinContraindicated in G6PDH-deficiency. Contraindicated at the end of the pregnancy for risk of haemolytic anaemia in the new-born.B
To be avoided (except when lifesaving)
AminoglycosidesAssociated with ototoxicity in the foetus and newborn.D
FluoroquinolonesAssociated with abnormalities in the development of cartilages in animal studiesC
TetracyclineCause of various bone abnormalities.D
SulphonamidesSulfamethoxazole/trimethoprim is a folic acid antagonist that increases the risk of kernicterus. D
FDA site of the Food and Drug Administration; FDA rating: B. No evidence of risk in studies; C. Risk cannot be ruled out; D. Positive evidence of risk.
Table A4. Other commonly prescribed drugs for CKD patients in pregnancy.
Table A4. Other commonly prescribed drugs for CKD patients in pregnancy.
DrugMain FeaturesFDA
Usually considered as relatively safe, when absolutely needed
Acetylsalicylate At low doses may protect against pre-eclampsia; discontinuation before delivery is recommended.A
Low molecular weight heparin Do not cross the placenta. Safe for prophylaxis and treatment of thromboembolic complications in pregnancy and post-partum. B
ESAsDo not cross the placenta and are considered safe; there may a need to increase doses in pregnancy.Not assigned
AllopurinolCrosses the placenta. Animal reproduction studies have shown potential adverse effects on the fetus. No adequate studies in humans. Potential benefits may warrant use of in pregnant women despite potential risks.C
Vitamin DNo advantage when given regardless of blood levels Vitamin D3 is recommended to correct deficiency. Cholecalciferol crosses the placenta but the transfer to the fetus is low; no evidence of adverse effects. Calcitriol, paricalcitol are teratogenic in animal studies. Animal studies have shown adverse effects of Ergocalciferol on the fetus. No adequate study in humans.Not assigned
Cholecalciferol
C Ergocalciferol
Iron supplementsMultivitamin with iron is only recommended for use in pregnancy when benefit outweighs risk. Ferrous sulfate use is the most frequently used. Maternal anemia increases the risk of low birth-weight, premature delivery, and impaired cognitive development. Recent studies have linked high serum iron with an increased risk of gestational diabetesA
Multivitamin with iron
Not assigned
Ferrous sulfate
Sodium bicarbonateNo animal or human data availale. Sodium bicarbonate should only be given during pregnancy when benefit outweighs riskC
Calcium carbonateMalformation risk is unlikely in humans. In some patients, permanent hypercalcemia resulted in adverse effects on the fetus. No available data in humans. Low intake is associated with adverse pregnancy events. Not assigned
To be avoided
WarfarinEvidence of teratogenicity in animal studies. In humans, exposure during the first trimester caused congenital malformations in about 5% of the exposed. Mental retardation, blindness, schizencephaly, microcephaly, hydrocephalus, and other adverse pregnancy outcomes have been reported following exposure in the second and third trimesters. Fatal fetal hemorrhage and an increased risk of spontaneous abortion and fetal mortality are also reported. Case by case evaluation in the case of cardiac indications.Not assigned
Novel anticoagulantsAnimal studies show adverse effects for Rivaroxaban, Dabigatran and Edoxaban. No adequate study in humans, but potential benefits may warrant use in highly selected cases. C
CalcimimeticsAnimal studies show adverse effects, and there is no adequate study in humans; potential benefits may warrant use in highly selected cases.C
SevelamerAnimal studies show adverse effects, and there is no adequate study in humans; potential benefits may warrant use in highly selected casesC
FDA site of the Food and Drug Administration; FDA rating: A. Controlled human studies show no risk; B. No evidence of risk in studies; C. Risk cannot be ruled out.

References

  1. Davison, J.M.; Lindheimer, M.D. Pregnancy and chronic kidney disease. Semin. Nephrol. 2011, 31, 86–99. [Google Scholar] [CrossRef] [PubMed]
  2. Hall, M. Pregnancy in Women with CKD: A Success Story. Am. J. Kidney Dis. 2016, 68, 633–639. [Google Scholar] [CrossRef] [PubMed]
  3. Piccoli, G.B.; Cabiddu, G. Pregnancy and kidney disease: From medicine based on exceptions to exceptional medicine. J. Nephrol. 2017, 30, 303–305. [Google Scholar] [CrossRef] [PubMed]
  4. Zhang, J.J.; Ma, X.X.; Hao, L.; Liu, L.J.; Lv, J.C.; Zhang, H. A Systematic Review and Meta-Analysis of Outcomes of Pregnancy in CKD and CKD Outcomes in Pregnancy. Clin. J. Am. Soc. Nephrol. 2015, 10, 1964–1978. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  5. Nevis, I.F.; Reitsma, A.; Dominic, A.; McDonald, S.; Thabane, L.; Akl, E.A.; Hladunewich, M.; Akbari, A.; Joseph, G.; Sia, W.; et al. Pregnancy outcomes in women with chronic kidney disease: A systematic review. Clin. J. Am. Soc. Nephrol. 2011, 6, 2587–2598. [Google Scholar] [CrossRef] [PubMed]
  6. Cabiddu, G.; Castellino, S.; Gernone, G.; Santoro, D.; Moroni, G.; Giannattasio, M.; Gregorini, G.; Giacchino, F.; Attini, R.; Loi, V.; et al. A best practice position statement on pregnancy in chronic kidney disease: The Italian Study Group on Kidney and Pregnancy. J. Nephrol. 2016, 29, 277–303. [Google Scholar] [CrossRef] [PubMed]
  7. Blom, K.; Odutayo, A.; Bramham, K.; Hladunewich, M.A. Pregnancy and Glomerular Disease: A Systematic Review of the Literature with Management Guidelines. Clin. J. Am. Soc. Nephrol. 2017, 12, 1862–1872. [Google Scholar] [CrossRef] [PubMed]
  8. August, P. Obstetric nephrology: Pregnancy and the kidney—Inextricably linked. Clin. J. Am. Soc. Nephrol. 2012, 7, 2071–2072. [Google Scholar] [CrossRef] [PubMed]
  9. Gianfreda, D.; Quaglini, S.; Frontini, G.; Raffiotta, F.; Messa, P.; Moroni, G. Does pregnancy have any impact on long term damage accrual and on the outcome of lupus nephritis? J. Autoimmun. 2017, 84, 46–54. [Google Scholar] [CrossRef] [PubMed]
  10. Hladunewich, M.A.; Hou, S.; Odutayo, A.; Cornelis, T.; Pierratos, A.; Goldstein, M.; Tennankore, K.; Keunen, J.; Hui, D.; Chan, C.T. Intensive hemodialysis associates with improved pregnancy outcomes: A Canadian and United States cohort comparison. J. Am. Soc. Nephrol. 2014, 25, 1103–1109. [Google Scholar] [CrossRef] [PubMed]
  11. Webster, P.; Lightstone, L.; McKay, D.B.; Josephson, M.A. Pregnancy in chronic kidney disease and kidney transplantation. Kidney Int. 2017, 91, 1047–1056. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  12. Kendrick, J.; Sharma, S.; Holmen, J.; Palit, S.; Nuccio, E.; Chonchol, M. Kidney disease and maternal and fetal outcomes in pregnancy. Am. J. Kidney Dis. 2015, 66, 55–59. [Google Scholar] [CrossRef] [PubMed]
  13. Piccoli, G.B.; Alrukhaimi, M.; Liu, Z.H.; Zakharova, E.; Levin, A.; World Kidney Day Steering Committee. What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman’s Day. BMC Nephrol. 2018, 19, 66. [Google Scholar] [CrossRef] [PubMed]
  14. Cornelis, T.; Odutayo, A.; Keunen, J.; Hladunewich, M. The kidney in normal pregnancy and preeclampsia. Semin. Nephrol. 2011, 31, 4–14. [Google Scholar] [CrossRef] [PubMed]
  15. Maynard, S.E.; Thadhani, R. Pregnancy and the kidney. J. Am. Soc. Nephrol. 2009, 20, 14–22. [Google Scholar] [CrossRef] [PubMed]
  16. Bjornstad, P.; Cherney, D.Z.I. Kidney Function Can Predict Pregnancy Outcomes. Clin. J. Am. Soc. Nephrol. 2017, 12, 1029–1031. [Google Scholar] [CrossRef] [PubMed]
  17. Kattah, A.; Milic, N.; White, W.; Garovic, V. Spot urine protein measurements in normotensive pregnancies, pregnancies with isolated proteinuria and preeclampsia. Am. J. Physiol. Regul. Integr. Comp. Physiol. 2017, 313, R418–R424. [Google Scholar] [CrossRef] [PubMed]
  18. August, P. Preeclampsia: A “nephrocentric” view. Adv. Chronic. Kidney Dis. 2013, 20, 280–286. [Google Scholar] [CrossRef] [PubMed]
  19. Kallela, J.; Jääskeläinen, T.; Kortelainen, E.; Heinonen, S.; Kajantie, E.; Kere, J.; Kivinen, K.; Pouta, A.; Laivuori, H. The diagnosis of pre-eclampsia using two revised classifications in the Finnish Pre-eclampsia Consortium (FINNPEC) cohort. BMC Pregnancy Childbirth 2016, 16. [Google Scholar] [CrossRef] [PubMed]
  20. Jim, B.; Garovic, V.D. Acute Kidney Injury in Pregnancy. Semin. Nephrol. 2017, 37, 378–385. [Google Scholar] [CrossRef] [PubMed]
  21. Yamada, T.; Obata-Yasuoka, M.; Hamada, H.; Baba, Y.; Ohkuchi, A.; Yasuda, S.; Kawabata, K.; Minakawa, S.; Hirai, C.; Kusaka, H.; et al. Isolated gestational proteinuria preceding the diagnosis of preeclampsia—An observational study. Acta Obstet. Gynecol. Scand. 2016, 95, 1048–1054. [Google Scholar] [CrossRef] [PubMed]
  22. Shinar, S.; Asher-Landsberg, J.; Schwartz, A.; Ram-Weiner, M.; Kupferminc, M.J.; Many, A. Isolated proteinuria is a risk factor for pre-eclampsia: A retrospective analysis of the maternal and neonatal outcomes in women presenting with isolated gestational proteinuria. J. Perinatol. 2016, 36, 25–29. [Google Scholar] [CrossRef] [PubMed]
  23. Morikawa, M.; Yamada, T.; Minakami, H. Outcome of pregnancy in patients with isolated proteinuria. Curr. Opin. Obstet. Gynecol. 2009, 21, 491–495. [Google Scholar] [CrossRef] [PubMed]
  24. Imbasciati, E.; Gregorini, G.; Cabiddu, G.; Gammaro, L.; Ambroso, G.; Del Giudice, A.; Ravani, P. Pregnancy in CKD stages 3 to 5: Fetal and maternal outcomes. Am. J. Kidney Dis. 2007, 49, 753–762. [Google Scholar] [CrossRef] [PubMed]
  25. Garg, A.X.; Nevis, I.F.; McArthur, E.; Sontrop, J.M.; Koval, J.J.; Lam, N.N.; Hildebrand, A.M.; Reese, P.P.; Storsley, L.; Gill, J.S.; et al. Gestational hypertension and preeclampsia in living kidney donors. N. Engl. J. Med. 2015, 372, 124–133. [Google Scholar] [CrossRef] [PubMed]
  26. Josephson, M.A. Transplantation: Pregnancy after kidney donation: More questions than answers. Nat. Rev. Nephrol. 2009, 5, 495–497. [Google Scholar] [CrossRef] [PubMed]
  27. Piccoli, G.B.; Attini, R.; Vasario, E.; Conijn, A.; Biolcati, M.; D’Amico, F.; Consiglio, V.; Bontempo, S.; Todros, T. Pregnancy and chronic kidney disease: A challenge in all CKD stages. Clin. J. Am. Soc. Nephrol. 2010, 5, 844–855. [Google Scholar] [CrossRef] [PubMed]
  28. Piccoli, G.B.; Cabiddu, G.; Attini, R.; Vigotti, F.N.; Maxia, S.; Lepori, N.; Tuveri, M.; Massidda, M.; Marchi, C.; Mura, S.; et al. Risk of Adverse Pregnancy Outcomes in Women with CKD. J. Am. Soc. Nephrol. 2015, 26, 2011–2022. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  29. Seeger, H.; Salfeld, P.; Eisel, R.; Wagner, C.A.; Mohebbi, N. Complicated pregnancies in inherited distal renal tubular acidosis: Importance of acid-base balance. J. Nephrol. 2017, 30, 455–460. [Google Scholar] [CrossRef] [PubMed]
  30. Yefet, E.; Tovbin, D.; Nachum, Z. Pregnancy outcomes in patients with Alport syndrome. Arch. Gynecol. Obstet. 2016, 293, 739–747. [Google Scholar] [CrossRef] [PubMed]
  31. Hladunewich, M.A.; Kim, S.J. Kidney Donation: What Might It Mean for Women Wishing to Become Pregnant. Am. J. Kidney Dis. 2015, 66, 386–388. [Google Scholar] [CrossRef] [PubMed]
  32. Ibrahim, H.N.; Akkina, S.K.; Leister, E.; Gillingham, K.; Cordner, G.; Guo, H.; Bailey, R.; Rogers, T.; Matas, A.J. Pregnancy outcomes after kidney donation. Am. J. Transplant. 2009, 9, 825–834. [Google Scholar] [CrossRef] [PubMed]
  33. Reisaeter, A.V.; Røislien, J.; Henriksen, T.; Irgens, L.M.; Hartmann, A. Pregnancy and birth after kidney donation: The Norwegian experience. Am J Transplant. 2009, 9, 820–824. [Google Scholar] [CrossRef] [PubMed]
  34. Klemetti, M.M.; Laivuori, H.; Tikkanen, M.; Nuutila, M.; Hiilesmaa, V.; Teramo, K. Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988–2011. Diabetologia 2015, 58, 678–686. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  35. Piccoli, G.B.; Clari, R.; Ghiotto, S.; Castelluccia, N.; Colombi, N.; Mauro, G.; Tavassoli, E.; Melluzza, C.; Cabiddu, G.; Gernone, G.; et al. Type 1 diabetes, diabetic nephropathy, and pregnancy: A systematic review and meta-study. Rev. Diabet. Stud. 2013, 10, 6–26. [Google Scholar] [CrossRef] [PubMed]
  36. Mathiesen, E.R.; Ringholm, L.; Feldt-Rasmussen, B.; Clausen, P.; Damm, P. Obstetric nephrology: Pregnancy in women with diabetic nephropathy—The role of antihypertensive treatment. Clin. J. Am. Soc. Nephrol. 2012, 7, 2081–2088. [Google Scholar] [CrossRef] [PubMed]
  37. Bramham, K. Diabetic Nephropathy and Pregnancy. Semin. Nephrol. 2017, 37, 362–369. [Google Scholar] [CrossRef] [PubMed]
  38. Lightstone, L.; Hladunewich, M.A. Lupus Nephritis and Pregnancy: Concerns and Management. Semin. Nephrol. 2017, 37, 347–353. [Google Scholar] [CrossRef] [PubMed]
  39. Buyon, J.P.; Kim, M.Y.; Guerra, M.M.; Laskin, C.A.; Petri, M.; Lockshin, M.D.; Sammaritano, L.; Branch, D.W.; Porter, T.F.; Sawitzke, A.; et al. Predictors of pregnancy outcomes in patients with lupus: A cohort study. Ann. Intern. Med. 2015, 163, 153–163. [Google Scholar] [CrossRef] [PubMed]
  40. Moroni, G.; Doria, A.; Giglio, E.; Imbasciati, E.; Tani, C.; Zen, M.; Strigini, F.; Zaina, B.; Tincani, A.; Gatto, M.; et al. Maternal outcome in pregnant women with lupus nephritis. A prospective multicenter study. J. Autoimmun. 2016, 74, 194–200. [Google Scholar] [CrossRef] [PubMed]
  41. Bramham, K.; Seed, P.T.; Lightstone, L.; Nelson-Piercy, C.; Gill, C.; Webster, P.; Poston, L.; Chappell, L.C. Diagnostic and predictive biomarkers for pre-eclampsia in patients with established hypertension and chronic kidney disease. Kidney Int. 2016, 89, 874–885. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  42. Hussain, A.; Karovitch, A.; Carson, M.P. Blood pressure goals and treatment in pregnant patients with chronic kidney disease. Adv. Chronic. Kidney Dis. 2015, 22, 165–169. [Google Scholar] [CrossRef] [PubMed]
  43. Piccoli, G.B.; Cabiddu, G.; Attini, R.; Parisi, S.; Fassio, F.; Loi, V.; Gerbino, M.; Biolcati, M.; Pani, A.; Todros, T. Hypertension in CKD Pregnancy: A Question of Cause and Effect (Cause or Effect? This Is the Question). Curr. Hypertens. Rep. 2016, 18. [Google Scholar] [CrossRef] [PubMed]
  44. De Castro, I.; Easterling, T.R.; Bansal, N.; Jefferson, J.A. Nephrotic syndrome in pregnancy poses risks with both maternal and fetal complications. Kidney Int. 2017, 91, 1464–1472. [Google Scholar] [CrossRef] [PubMed]
  45. Su, X.; Lv, J.; Liu, Y.; Wang, J.; Ma, X.; Shi, S.; Liu, L.; Zhang, H. Pregnancy and Kidney Outcomes in Patients With IgA Nephropathy: A Cohort Study. Am. J. Kidney Dis. 2017, 70, 262–269. [Google Scholar] [CrossRef] [PubMed]
  46. Liu, Y.; Ma, X.; Zheng, J.; Liu, X.; Yan, T. A Systematic Review and Meta-Analysis of Kidney and Pregnancy Outcomes in IgA Nephropathy. Am. J. Nephrol. 2016, 44, 187–193. [Google Scholar] [CrossRef] [PubMed]
  47. Piccoli, G.B.; Attini, R.; Cabiddu, G.; Kooij, I.; Fassio, F.; Gerbino, M.; Maxia, S.; Biolcati, M.; Versino, E.; Todros, T. Maternal-foetal outcomes in pregnant women with glomerulonephritides. Are all glomerulonephritides alike in pregnancy? J. Autoimmun. 2017, 79, 91–98. [Google Scholar] [CrossRef] [PubMed]
  48. Piccoli, G.B.; Kooij, I.A.; Attini, R.; Montersino, B.; Fassio, F.; Gerbino, M.; Biolcati, M.; Cabiddu, G.; Versino, E.; Todros, T. A Systematic Review on Materno-Foetal Outcomes in Pregnant Women with IgA Nephropathy: A Case of “Late-Maternal” Preeclampsia? J. Clin. Med. 2018, 7. [Google Scholar] [CrossRef] [PubMed]
  49. Hollowell, J.G. Outcome of pregnancy in women with a history of vesico-ureteric reflux. BJU Int. 2008, 102, 780–784. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  50. Attini, R.; Kooij, I.; Montersino, B.; Fassio, F.; Gerbino, M.; Biolcati, M.; Versino, E.; Todros, T.; Piccoli, G.B. Reflux nephropathy and the risk of preeclampsia and of other adverse pregnancy-related outcomes: A systematic review and meta-analysis of case series and reports in the new millennium. J. Nephrol. 2018. [Google Scholar] [CrossRef] [PubMed]
  51. Wu, M.; Wang, D.; Zand, L.; Harris, P.C.; White, W.M.; Garovic, V.D.; Kermott, C.A. Pregnancy outcomes in autosomal dominant polycystic kidney disease: A case-control study. J. Matern. Fetal Neonatal Med. 2016, 29, 807–812. [Google Scholar] [CrossRef] [PubMed]
  52. Tong, A.; Jesudason, S.; Craig, J.C.; Winkelmayer, W.C. Perspectives on pregnancy in women with chronic kidney disease: Systematic review of qualitative studies. Nephrol. Dial. Transplant. 2015, 30, 652–661. [Google Scholar] [CrossRef] [PubMed]
  53. Tong, A.; Brown, M.A.; Winkelmayer, W.C.; Craig, J.C.; Jesudason, S. Perspectives on Pregnancy in Women with CKD: A Semistructured Interview Study. Am. J. Kidney Dis. 2015, 66, 951–961. [Google Scholar] [CrossRef] [PubMed]
  54. Smyth, A.; Oliveira, G.H.; Lahr, B.D.; Bailey, K.R.; Norby, S.M.; Garovic, V.D. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis. Clin. J. Am. Soc. Nephrol. 2010, 5, 2060–2068. [Google Scholar] [CrossRef] [PubMed]
  55. Carvalheiras, G.; Vita, P.; Marta, S.; Trovão, R.; Farinha, F.; Braga, J.; Rocha, G.; Almeida, I.; Marinho, A.; Mendonça, T.; et al. Pregnancy and systemic lupus erythematosus: Review of clinical features and outcome of 51 pregnancies at a single institution. Clin. Rev. Allergy Immunol. 2010, 38, 302–306. [Google Scholar] [CrossRef] [PubMed]
  56. Tower, C.; Mathen, S.; Crocker, I.; Bruce, I.N. Regulatory T cells in systemic lupus erythematosus and pregnancy. Am. J. Reprod. Immunol. 2013, 69, 588–595. [Google Scholar] [CrossRef] [PubMed]
  57. Niewold, T.B.; Hua, J.; Lehman, T.J.; Harley, J.B.; Crow, M.K. High serum IFN-alpha activity is a heritable risk factor for systemic lupus erythematosus. Genes Immun. 2007, 8, 492–502. [Google Scholar] [CrossRef] [PubMed]
  58. Buyon, J.P.; Kim, M.Y.; Guerra, M.M.; Lu, S.; Reeves, E.; Petri, M.; Laskin, C.A.; Lockshin, M.D.; Sammaritano, L.R.; Branch, D.W.; et al. Kidney Outcomes and Risk Factors for Nephritis (Flare/De Novo) in a Multiethnic Cohort of Pregnant Patients with Lupus. Clin. J. Am. Soc. Nephrol. 2017, 12, 940–946. [Google Scholar] [CrossRef] [PubMed]
  59. Buyon, J.P.; Kim, M.Y.; Salmon, J.E. Predictors of Pregnancy Outcomes in Patients with Lupus. Ann. Intern. Med. 2016, 164, 131. [Google Scholar] [CrossRef] [PubMed]
  60. Hughes, G.R. The antiphospholipid syndrome: Ten years on. Lancet 1993, 342, 341–344. [Google Scholar] [CrossRef]
  61. Miyakis, S.; Lockshin, M.D.; Atsumi, T.; Branch, D.W.; Brey, R.L.; Cervera, R.; Derksen, R.H.; DEGroot, P.G.; Koike, T.; Meroni, P.L.; et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J. Thromb. Haemost. 2006, 4, 295–306. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  62. Di Simone, N.; Di Nicuolo, F.; D’Ippolito, S.; Castellani, R.; Tersigni, C.; Caruso, A.; Meroni, P.; Marana, R. Antiphospholipid antibodies affect human endometrial angiogenesis. Biol. Reprod. 2010, 83, 212–219. [Google Scholar] [CrossRef] [PubMed]
  63. Di Simone, N.; D’Ippolito, S.; Marana, R.; Di Nicuolo, F.; Castellani, R.; Pierangeli, S.S.; Chen, P.; Tersigni, C.; Scambia, G.; Meroni, P.L. Antiphospholipid antibodies affect human endometrial angiogenesis: Protective effect of a synthetic peptide (TIFI) mimicking the phospholipid binding site of β(2) glycoprotein I. Am. J. Reprod. Immunol. 2013, 70, 299–308. [Google Scholar] [CrossRef] [PubMed]
  64. D’Ippolito, S.; Marana, R.; Di Nicuolo, F.; Castellani, R.; Veglia, M.; Stinson, J.; Scambia, G.; Di Simone, N. Effect of Low Molecular Weight Heparins (LMWHs) on antiphospholipid Antibodies (aPL)-mediated inhibition of endometrial angiogenesis. PLoS ONE 2012, 7, e29660. [Google Scholar] [CrossRef] [PubMed]
  65. Asherson, R.A.; Khamashta, M.A.; Ordi-Ros, J.; Derksen, R.H.; Machin, S.J.; Barquinero, J.; Outt, H.H.; Harris, E.N.; Vilardell-Torres, M.; Hughes, G.R. The “primary” antiphospholipid syndrome: Major clinical and serological features. Medicine 1989, 8, 366–374. [Google Scholar] [CrossRef]
  66. Kochenour, N.K.; Branch, D.W.; Rote, N.S.; Scott, J.R. A new postpartum syndrome associated with antiphospholipid antibodies. Obstet. Gynecol. 1987, 69, 460–468. [Google Scholar] [PubMed]
  67. Ruffatti, A.; Calligaro, A.; Hoxha, A.; Trevisanuto, D.; Ruffatti, A.T.; Gervasi, M.T.; Cuffaro, S.; Pengo, V.; Punzi, L. Laboratory and clinical features of pregnant women with antiphospholipid syndrome and neonatal outcome. Arthritis Care Res. 2010, 62, 302–307. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  68. Pengo, V.; Banzato, A.; Bison, E.; Bracco, A.; Denas, G.; Ruffatti, A. What have we learned about antiphospholipid syndrome from patients and antiphospholipid carrier cohorts? Semin. Thromb. Hemost. 2012, 38, 322–327. [Google Scholar] [CrossRef] [PubMed]
  69. Hanouna, G.; Morel, N.; Le Thi Huong, D.; Josselin, L.; Vauthier-Brouzes, D.; Saadoun, D.; Kettaneh, A.; Levesque, K.; Le Guern, V.; Goffinet, F.; et al. Catastrophic antiphospholipid syndrome and pregnancy: An experience of 13 cases. Rheumatology 2013, 52, 1635–1641. [Google Scholar] [CrossRef] [PubMed]
  70. Smyth, A.; Garovich, V. Glomerular Disease in Pregnancy. In Core Concepts in Parenchymal Kidney Disease; Fervenza, F.C., Lin, J., Sethi, S., Singh, A.K., Eds.; Springer-Verlag: New York, NY, USA, 2014. [Google Scholar]
  71. Krause, M.L.; Makol, A. Management of rheumatoid arthritis during pregnancy: Challenges and solutions. Open Access Rheumatol. 2016, 8, 23–36. [Google Scholar] [PubMed]
  72. Brouwer, J.; Hazes, J.M.; Laven, J.S.; Dolhain, R.J. Fertility in women with rheumatoid arthritis: Influence of disease activity and medication. Ann. Rheum. Dis. 2015, 74, 1836–1841. [Google Scholar] [CrossRef] [PubMed]
  73. De Man, Y.A.; Dolhain, R.J.; van de Geijn, F.E.; Willemsen, S.P.; Hazes, J.M. Disease activity of rheumatoid arthritis during pregnancy: Results from a nationwide prospective study. Arthritis Rheum. 2008, 59, 1241–1248. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  74. Barrett, J.H.; Brennan, P.; Fiddler, M.; Silman, A.J. Does rheumatoid arthritis remit during pregnancy and relapse postpartum? Results from a nationwide study in the United Kingdom performed prospectively from late pregnancy. Arthritis Rheum. 1999, 42, 1219–1227. [Google Scholar] [CrossRef]
  75. Myasoedova, E.; Crowson, C.S.; Kremers, H.M.; Therneau, T.M.; Gabriel, S.E. Is the incidence of rheumatoid arthritis rising?: Results from Olmsted County, Minnesota, 1955-2007. Arthritis Rheum. 2010, 62, 1576–1582. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  76. Icardi, A.; Araghi, P.; Ciabattoni, M.; Romano, U.; Lazzarini, P.; Bianchi, G. Kidney involvement in rheumatoid arthritis. Reumatismo 2003, 55, 76–85. [Google Scholar] [CrossRef] [PubMed]
  77. Anders, H.J.; Vielhauer, V. Renal co-morbidity in patients with rheumatic diseases. Arthritis Res. Ther. 2011, 13, 222. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  78. Chiu, H.Y.; Huang HL2 Li, C.H.; Chen, H.A.; Yeh, C.L.; Chiu, S.H.; Lin, W.C.; Cheng, Y.P.; Tsai, T.F.; Ho, S. Increased Risk of Chronic Kidney Disease in Rheumatoid Arthritis Associated with Cardiovascular Complications—A National Population-Based Cohort Study. PLoS ONE 2015, 10, e0136508. [Google Scholar] [CrossRef] [PubMed]
  79. Rom, A.L.; Wu, C.S.; Olsen, J.; Kjaergaard, H.; Jawaheer, D.; Hetland, M.L.; Vestergaard, M.; Mørch, L.S. Fetal growth and preterm birth in children exposed to maternal or paternal rheumatoid arthritis: A nationwide cohort study. Arthritis Rheumatol. 2014, 66, 3265–3273. [Google Scholar] [CrossRef] [PubMed]
  80. Lin, H.C.; Chen, S.F.; Lin, H.C.; Chen, Y.H. Increased risk of adverse pregnancy outcomes in women with rheumatoid arthritis: A nationwide population-based study. Ann. Rheum. Dis. 2010, 69, 715–717. [Google Scholar] [CrossRef] [PubMed]
  81. Sammaritano, L.R. Menopause in patients with autoimmune diseases. Autoimmun. Rev. 2012, 11, A430–A436. [Google Scholar] [CrossRef] [PubMed]
  82. Steen, V.D.; Syzd, A.; Johnson, J.P.; Greenberg, A.; Medsger, T.A., Jr. Kidney disease other than renal crisis in patients with diffuse scleroderma. J. Rheumatol. 2005, 32, 649–655. [Google Scholar] [PubMed]
  83. Sobanski, V.; Launay, D.; Depret, S.; Ducloy-Bouthors, A.S.; Hachulla, E. Special considerations in pregnant systemic sclerosis patients. Expert Rev. Clin. Immunol. 2016, 12, 1161–1173. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  84. Chakravarty, E.F.; Khanna, D.; Chung, L. Pregnancy outcomes in systemic sclerosis, primary pulmonary hypertension, and sickle cell disease. Obstet. Gynecol. 2008, 111, 927–934. [Google Scholar] [CrossRef] [PubMed]
  85. Williams, D.; Davison, J. Chronic kidney disease in pregnancy. BMJ 2008, 336, 211–215. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  86. Mol, B.W.J.; Roberts, C.T.; Thangaratinam, S.; Magee, L.A.; de Groot, C.J.M.; Hofmeyr, G.J. Pre-eclampsia. Lancet 2016, 387, 999–1011. [Google Scholar] [CrossRef]
  87. Luyckx, V.A.; Tonelli, M.; Stanifer, J.W. The global burden of kidney disease and the sustainable development goals. Bull. World Health Organ. 2018, 96, 414–422. [Google Scholar] [CrossRef] [PubMed]
  88. Stanifer, J.W.; Von Isenburg, M.; Chertow, G.M.; Anand, S. Chronic kidney disease care models in low- and middle-income countries: A systematic review. BMJ Glob. Health 2018, 3, e000728. [Google Scholar] [CrossRef] [PubMed]
  89. Koye, D.N.; Magliano, D.J.; Nelson, R.G.; Pavkov, M.E. The Global Epidemiology of Diabetes and Kidney Disease. Adv. Chronic. Kidney Dis. 2018, 25, 121–132. [Google Scholar] [CrossRef] [PubMed]
  90. Garcia-Garcia, G.; Jha, V.; World Kidney Day Steering Committee. Chronic kidney disease in disadvantaged populations. Nephron Clin. Pract. 2014, 128, 292–296. [Google Scholar] [CrossRef] [PubMed]
  91. Perico, N.; Remuzzi, G. Prevention programs for chronic kidney disease in low-income countries. Intern. Emerg. Med. 2016, 11, 385–389. [Google Scholar] [CrossRef] [PubMed]
  92. Ibarra-Hernández, M.; Orozco-Guillén, O.A.; de la Alcantar-Vallín, M.L.; Garrido-Roldan, R.; Jiménez-Alvarado, M.P.; Castro, K.B.; Villa-Villagrana, F.; Borbolla, M.; Gallardo-Gaona, J.M.; García-García, G.; et al. Acute kidney injury in pregnancy and the role of underlying CKD: A point of view from México. J. Nephrol. 2017, 30, 773–780. [Google Scholar] [CrossRef] [PubMed]
  93. Agampodi, S.B.; Wijerathne, B.T. Baseline renal function of pregnant women in a geographical region with an epidemic of chronic kidney disease of unknown aetiology in Sri Lanka. Nephrology 2016, 21, 794–795. [Google Scholar] [CrossRef] [PubMed]
  94. Piccoli, G.B.; Fassio, F.; Attini, R.; Parisi, S.; Biolcati, M.; Ferraresi, M.; Pagano, A.; Daidola, G.; Deagostini, M.C.; Gaglioti, P.; et al. Pregnancy in CKD: Whom should we follow and why? Nephrol. Dial. Transplant. 2012, 27, 111–118. [Google Scholar] [CrossRef] [PubMed]
  95. Antenatal care for uncomplicated pregnancies | Guidance and guidelines | NICE. Available online: https://www.nice.org.uk/Guidance/cg62 (accessed on 10 July 2018).
  96. Gravidanza Basso Rischio. Available online: http://www.aogoi.it/media/1058/gravidanza_basso_rischio.pdf (accessed on 10 July 2018).
  97. Haute Autorité de Santé—Suivi et Orientation des Femmes Enceintes en Fonction des Situations à Risque Identifiées. Available online: https://www.has-sante.fr/portail/jcms/c_547976/fr/suivi-et-orientation-des-femmes-enceintes-en-fonction-des-situations-a-risque-identifiees (accessed on 10 July 2018).
  98. Shahraki, A.D.; Bardeh, M.E.; Najarzadegan, M.R. Investigation of the relationship between idiopathic microscopic hematuria (in the first and second trimesters) and major adverse outcomes of pregnancy. Adv. Biomed. Res. 2016, 5, 186. [Google Scholar] [PubMed]
  99. Brown, M.A.; Holt, J.L.; Mangos, G.J.; Murray, N.; Curtis, J.; Homer, C. Microscopic hematuria in pregnancy: Relevance to pregnancy outcome. Am. J. Kidney Dis. 2005, 45, 667–673. [Google Scholar] [CrossRef] [PubMed]
  100. Szeto, C.C.; To, K.F.; Lai, F.M.; Chow, K.M.; Tam, W.H.; Chung, K.Y.; Leung, C.B.; Lui, S.F.; Li, P.K.; Lau, T.K. Prevalence and implications of isolated microscopic hematuria in asymptomatic Chinese pregnant women. Nephron Clin. Pract. 2007, 105, c147–c152. [Google Scholar] [CrossRef] [PubMed]
  101. Rolfo, A.; Attini, R.; Tavassoli, E.; Neve, F.V.; Nigra, M.; Cicilano, M.; Nuzzo, A.M.; Giuffrida, D.; Biolcati, M.; Nichelatti, M.; et al. Is It Possible to Differentiate Chronic Kidney Disease and Preeclampsia by means of New and Old Biomarkers? A Prospective Study. Dis. Markers 2015, 2015, 127083. [Google Scholar] [CrossRef] [PubMed]
  102. Piccoli, G.B.; Gaglioti, P.; Attini, R.; Parisi, S.; Bossotti, C.; Olearo, E.; Oberto, M.; Ferraresi, M.; Rolfo, A.; Versino, E.; et al. Pre-eclampsia or chronic kidney disease? The flow hypothesis. Nephrol. Dial. Transplant. 2013, 28, 1199–1206. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  103. Rolfo, A.; Attini, R.; Nuzzo, A.M.; Piazzese, A.; Parisi, S.; Ferraresi, M.; Todros, T.; Piccoli, G.B. Chronic kidney disease may be differentially diagnosed from preeclampsia by serum biomarkers. Kidney Int. 2013, 83, 177–181. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  104. Alkhunaizi, A.; Melamed, N.; Hladunewich, M.A. Pregnancy in advanced chronic kidney disease and end-stage renal disease. Curr. Opin. Nephrol. Hypertens. 2015, 24, 252–259. [Google Scholar] [CrossRef] [PubMed]
  105. Jesudason, S.; Grace, B.S.; McDonald, S.P. Pregnancy outcomes according to dialysis commencing before or after conception in women with ESRD. Clin. J. Am. Soc. Nephrol. 2014, 9, 143–149. [Google Scholar] [CrossRef] [PubMed]
  106. Piccoli, G.B.; Cabiddu, G.; Daidone, G.; Guzzo, G.; Maxia, S.; Ciniglio, I.; Postorino, V.; Loi, V.; Ghiotto, S.; Nichelatti, M.; et al. The children of dialysis: Live-born babies from on-dialysis mothers in Italy—An epidemiological perspective comparing dialysis, kidney transplantation and the overall population. Nephrol. Dial. Transplant. 2014, 29, 1578–1586. [Google Scholar] [CrossRef] [PubMed]
  107. Hladunewich, M.; Schatell, D. Intensive dialysis and pregnancy. Hemodial. Int. 2016, 20, 339–348. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  108. Hladunewich, M.; Hercz, A.E.; Keunen, J.; Chan, C.; Pierratos, A. Pregnancy in end stage renal disease. Semin. Dial. 2011, 24, 634–639. [Google Scholar] [CrossRef] [PubMed]
  109. Piccoli, G.B.; Minelli, F.; Versino, E.; Cabiddu, G.; Attini, R.; Vigotti, F.N.; Rolfo, A.; Giuffrida, D.; Colombi, N.; Pani, A.; et al. Pregnancy in dialysis patients in the new millennium: A systematic review and meta-regression analysis correlating dialysis schedules and pregnancy outcomes. Nephrol. Dial. Transplant. 2016, 31, 1915–1934. [Google Scholar] [CrossRef] [PubMed]
  110. Sachdeva, M.; Barta, V.; Thakkar, J.; Sakhiya, V.; Miller, I. Pregnancy outcomes in women on hemodialysis: A national survey. Clin. Kidney J. 2017, 10, 276–281. [Google Scholar] [CrossRef] [PubMed]
  111. Cabiddu, G.; Castellino, S.; Gernone, G.; Santoro, D.; Giacchino, F.; Credendino, O.; Daidone, G.; Gregorini, G.; Moroni, G.; Attini, R.; et al. Best practices on pregnancy on dialysis: The Italian Study Group on Kidney and Pregnancy. J. Nephrol. 2015, 28, 279–288. [Google Scholar] [CrossRef] [PubMed]
  112. Suarez, M.B.; Costa, M.L.; Parpinelli, M.Â.; Surita, F.G. Pregnancy in women undergoing hemodialysis: Case series in a Southeast Brazilian reference center. Rev. Bras. Ginecol. Obstet. 2015, 37, 5–9. [Google Scholar] [CrossRef] [PubMed]
  113. Duffner, J.; Schulte-Kemna, L.; Reister, B.; Ludwig, U.; Keller, F.; van Erp, R.; Schröppel, B. Survey among nephrologists in Germany: Current practice and management of pregnant women on dialysis. Clin. Nephrol. 2017, 88, 264–269. [Google Scholar] [CrossRef] [PubMed]
  114. Van Ek, G.F.; Krouwel, E.M.; Nicolai, M.P.J.; Den Oudsten, B.L.; Den Ouden, M.E.M.; Dieben, S.W.M.; Putter, H.; Pelger, R.C.M.; Elzevier, H.W. What is the role of nephrologists and nurses of the dialysis department in providing fertility care to CKD patients? A questionnaire study among care providers. Int. Urol. Nephrol. 2017, 49, 1273–1285. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  115. Hildebrand, A.M.; Liu, K.; Shariff, S.Z.; Ray, J.G.; Sontrop, J.M.; Clark, W.F.; Hladunewich, M.A.; Garg, A.X. Characteristics and Outcomes of AKI Treated with Dialysis during Pregnancy and the Postpartum Period. J. Am. Soc. Nephrol. 2015, 26, 3085–3091. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  116. Liu, Y.; Ma, X.; Zheng, J.; Liu, X.; Yan, T. Pregnancy outcomes in patients with acute kidney injury during pregnancy: A systematic review and meta-analysis. BMC Pregnancy Childbirth 2017, 17, 235. [Google Scholar] [CrossRef] [PubMed]
  117. Prakash, J.; Ganiger, V.C.; Prakash, S.; Iqbal, M.; Kar, D.P.; Singh, U.; Verma, A. Acute kidney injury in pregnancy with special reference to pregnancy-specific disorders: A hospital based study (2014–2016). J. Nephrol. 2018, 31, 79–85. [Google Scholar] [CrossRef] [PubMed]
  118. Nwoko, R.; Plecas, D.; Garovic, V.D. Acute kidney injury in the pregnant patient. Clin Nephrol 2012, 78, 478–486. [Google Scholar] [CrossRef] [PubMed]
  119. Leurs, P.; Machowska, A.; Lindholm, B. Timing of dialysis initiation: When to start? Which treatment? J. Ren. Nutr. 2015, 25, 238–241. [Google Scholar] [CrossRef] [PubMed]
  120. Rosansky, S.J.; Cancarini, G.; Clark, W.F.; Eggers, P.; Germaine, M.; Glassock, R.; Goldfarb, D.S.; Harris, D.; Hwang, S.J.; Imperial, E.B.; et al. Dialysis initiation: What’s the rush? Semin. Dial. 2013, 26, 650–657. [Google Scholar] [CrossRef] [PubMed]
  121. Rivara, M.B.; Mehrotra, R. Is early initiation of dialysis harmful? Semin. Dial. 2014, 27, 250–252. [Google Scholar] [CrossRef] [PubMed]
  122. Nesrallah, G.E.; Mustafa, R.A.; Clark, W.F.; Bass, A.; Barnieh, L.; Hemmelgarn, B.R.; Klarenbach, S.; Quinn, R.R.; Hiremath, S.; Ravani, P.; et al. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ 2014, 186, 112–117. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  123. Sato, J.L.; De Oliveira, L.; Kirsztajn, G.M.; Sass, N. Chronic kidney disease in pregnancy requiring first-timedialysis. Int. J. Gynaecol. Obstet. 2010, 111, 45–48. [Google Scholar] [CrossRef] [PubMed]
  124. Cornelis, T.; Spaanderman, M.; Beerenhout, C.; Perschel, F.H.; Verlohren, S.; Schalkwijk, C.G.; van der Sande, F.M.; Kooman, J.P.; Hladunewich, M. Antiangiogenic factors and maternal hemodynamics during intensive hemodialysis in pregnancy. Hemodial. Int. 2013, 17, 639–643. [Google Scholar] [CrossRef] [PubMed]
  125. Attini, R.; Leone, F.; Parisi, S.; Fassio, F.; Capizzi, I.; Loi, V.; Colla, L.; Rossetti, M.; Gerbino, M.; Maxia, S.; et al. Vegan-vegetarian low-protein supplemented diets in pregnant CKD patients: Fifteen years of experience. BMC Nephrol. 2016, 17. [Google Scholar] [CrossRef] [PubMed]
  126. Piccoli, G.B.; Clari, R.; Vigotti, F.N.; Leone, F.; Attini, R.; Cabiddu, G.; Mauro, G.; Castelluccia, N.; Colombi, N.; Capizzi, I.; et al. Vegan-vegetarian diets in pregnancy: Danger or panacea? A systematic narrative review. BJOG 2015, 122, 623–633. [Google Scholar] [CrossRef] [PubMed]
  127. Nava, J.; Moran, S.; Figueroa, V.; Salinas, A.; Lopez, M.; Urbina, R.; Gutierrez, A.; Lujan, J.L.; Orozco, A.; Montufar, R.; et al. Successful pregnancy in a CKD patient on a low-protein, supplemented diet: An opportunity to reflect on CKD and pregnancy in Mexico, an emerging country. J. Nephrol. 2017, 30, 877–882. [Google Scholar] [CrossRef] [PubMed]
  128. Leduc, V.; Ficheux, M.; Bechade, C.; Dreyfus, M.; Lobbedez, T.; Henri, P. Pregnancy on short-daily home hemodialysis using low dialysate flow rate: A new hope for the end-stage renal disease patients. Hemodial. Int. 2018, 22, 161–167. [Google Scholar] [CrossRef] [PubMed]
  129. Brahmbhatt, Y.; Ikeme, A.; Bhogal, N.; Berghella, V. Successful Pregnancy Using the NxStage Home Hemodialysis System. Case Rep. Nephrol. 2016, 2016, 1358625. [Google Scholar] [CrossRef] [PubMed]
  130. Choi, C.Y.; Cho, N.J.; Park, S.; Gil, H.W.; Kim, Y.S.; Lee, E.Y. A case report of successful pregnancy and delivery after peritoneal dialysis in a patient misdiagnosed with primary infertility. Medicine 2018, 97, 11148. [Google Scholar] [CrossRef] [PubMed]
  131. Lim, T.S.; Shanmuganathan, M.; Wong, I.; Goh, B.L. Successful multigravid pregnancy in a 42-year-old patient on continuous ambulatory peritoneal dialysis and a review of the literature. BMC Nephrol. 2017, 18. [Google Scholar] [CrossRef] [PubMed]
  132. Ross, L.E.; Swift, P.A.; Newbold, S.M.; Bramham, K.; Hurley, A.; Gallagher, H. An Alternative Approach to Delivering Intensive Dialysis in Pregnancy. Perit. Dial. Int. 2016, 36, 575–577. [Google Scholar] [CrossRef] [PubMed]
  133. Deshpande, N.A.; James, N.T.; Kucirka, L.M.; Boyarsky, B.J.; Garonzik-Wang, J.M.; Montgomery, R.A.; Segev, D.L. Pregnancy outcomes in kidney transplant recipients: A systematic review and meta-analysis. Am. J. Transplant. 2011, 11, 2388–2404. [Google Scholar] [CrossRef] [PubMed]
  134. Deshpande, N.A.; Coscia, L.A.; Gomez-Lobo, V.; Moritz, M.J.; Armenti, V.T. Pregnancy after solid organ transplantation: A guide for obstetric management. Rev. Obstet. Gynecol. 2013, 6, 116–125. [Google Scholar] [PubMed]
  135. Bramham, K.; Nelson-Piercy, C.; Gao, H.; Pierce, M.; Bush, N.; Spark, P.; Brocklehurst, P.; Kurinczuk, J.J.; Knight, M. Pregnancy in renal transplant recipients: A UK national cohort study. Clin. J. Am. Soc. Nephrol. 2013, 8, 290–298. [Google Scholar] [CrossRef] [PubMed]
  136. Mohammadi, F.A.; Borg, M.; Gulyani, A.; McDonald, S.P.; Jesudason, S. Pregnancy outcomes and impact of pregnancy on graft function in women after kidney transplantation. Clin. Transplant. 2017, 31. [Google Scholar] [CrossRef] [PubMed]
  137. Saber, L.T.; Duarte, G.; Costa, J.A.; Cologna, A.J.; Garcia, T.M.; Ferraz, A.S. Pregnancy and kidney transplantation: Experience in a developing country. Am. J. Kidney Dis. 1995, 25, 465–470. [Google Scholar] [CrossRef]
  138. Kwek, J.L.; Tey, V.; Yang, L.; Kanagalingam, D.; Kee, T. Renal and obstetric outcomes in pregnancy after kidney transplantation: Twelve-year experience in a Singapore transplant center. J. Obstet. Gynaecol. Res. 2015, 41, 1337–1344. [Google Scholar] [CrossRef] [PubMed]
  139. Ghanem, M.E.; El-Baghdadi, L.A.; Badawy, A.M.; Bakr, M.A.; Sobhe, M.A.; Ghoneim, M.A. Pregnancy outcome after renal allograft transplantation: 15 Years experience. Eur. J. Obstet. Gynecol. Reprod. Biol. 2005, 121, 178–181. [Google Scholar] [CrossRef] [PubMed]
  140. Cabiddu, G.; Spotti, D.; Gernone, G.; Santoro, D.; Moroni, G.; Gregorini, G.; Giacchino, F.; Attini, R.; Limardo, M.; Gammaro, L.; et al. A best-practice position statement on pregnancy after kidney transplantation: Focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology. J. Nephrol. 2018, 31, 665–681. [Google Scholar] [CrossRef] [PubMed]
  141. Piccoli, G.B.; Cabiddu, G.; Attini, R.; Gerbino, M.; Todeschini, P.; Perrino, M.L.; Manzione, A.M.; Piredda, G.B.; Gnappi, E.; Caputo, F.; et al. Outcomes of pregnancies after kidney transplantation: Lessons learned from CKD. A comparison of transplanted, nontransplanted chronic kidney disease patients and low-risk pregnancies: A multicenter nationwide analysis. Transplantation 2017, 101, 2536–2544. [Google Scholar] [CrossRef] [PubMed]
  142. Kukla, A.; Issa, N.; Ibrahim, H.N. Pregnancy in renal transplantation: Recipient and donor aspects in the Arab world. Arab. J. Urol. 2012, 10, 175–181. [Google Scholar] [CrossRef] [PubMed]
  143. EBPG Expert Group on Renal Transplantation. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.10. Pregnancy in renal transplant recipients. Nephrol. Dial. Transplant. 2002, 17, 50–55. [Google Scholar]
  144. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am. J. Transplant. 2009, 9, S1–S155. [Google Scholar] [CrossRef] [PubMed]
  145. Josephson, M.A.; McKay, D.B. Women and transplantation: Fertility, sexuality, pregnancy, contraception. Adv. Chronic. Kidney Dis. 2013, 20, 433–440. [Google Scholar] [CrossRef] [PubMed]
  146. Gizzo, S.; Noventa, M.; Saccardi, C.; Paccagnella, G.; Patrelli, T.S.; Cosmi, E.; D’Antona, D. Twin pregnancy after kidney transplantation: What’s on? A case report and review of literature. J. Matern. Fetal Neonatal Med. 2014, 27, 1816–1819. [Google Scholar] [CrossRef] [PubMed]
  147. Combs, J.; Kagan, A.; Boelkins, M.; Coscia, L.; Moritz, M.; Hofmann, R.M. Belatacept during pregnancy in renal transplant recipients: Two case reports. Am. J. Transplant. 2018, 18, 2079–2082. [Google Scholar] [CrossRef] [PubMed]
  148. Assalino, M.; Podetta, M.; Demuylder-Mischler, S.; Francini, K.; Pernin, N.; Randin, J.P.; Bosco, D.; Andres, A.; Berney, T. Successful pregnancy and delivery after simultaneous islet-kidney transplantation. Am. J. Transplant. 2018, 18, 2075–2078. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  149. Mahmoud, T.; Mujaibel, K.; Attia, H.; Zakaria, Z.; Yagan, J.; Gheith, O.; Halim, M.A.; Nair, P.; Al-Otaibi, T. Triplet Pregnancy in a Diabetic Mother With Kidney Transplant: Case Report and Review of the Literature. Exp. Clin. Transplant. 2017, 15, 139–146. [Google Scholar] [PubMed]
  150. Esposito, L.; Rostaing, L.; Kamar, N. Successful pregnancy after ABO-incompatible kidney transplantation. Transpl. Int. 2016, 29, 506–507. [Google Scholar] [CrossRef] [PubMed]
  151. Kennedy, C.; Hussein, W.; Spencer, S.; Walshe, J.; Denton, M.; Conlon, P.J.; Magee, C. Reproductive health in Irish female renal transplant recipients. Ir. J. Med. Sci. 2012, 181, 59–63. [Google Scholar] [CrossRef] [PubMed]
  152. Pietrzak, B.; Mazanowska, N.; Kociszewska-Najman, B.; Szymusik, I.; Grzechocińska, B.; Pazik, J.; Jabiry-Zieniewicz, Z.; Popow, A.; Wielgos, M. Successful Pregnancy Outcome after In Vitro Fertilization in a Kidney Graft Recipient: A Case Report and Literature Review. Ann. Transplant. 2015, 20, 338–341. [Google Scholar] [PubMed]
  153. Norrman, E.; Bergh, C.; Wennerholm, U.B. Pregnancy outcome and long-term follow-up after in vitro fertilization in women with renal transplantation. Hum. Reprod. 2015, 30, 205–213. [Google Scholar] [CrossRef] [PubMed]
  154. Zheng, H.H.; Song, Y.; Wu, J.Y. Critical Ovarian Hyperstimulation Syndrome After In Vitro Fertilization Treatment in a Renal Transplant Recipient: A Case Report. Transplant. Proc. 2016, 48, 267–270. [Google Scholar] [CrossRef] [PubMed]
  155. El Houssni, S.; Sabri, S.; Benamar, L.; Ouzeddoun, N.; Bayahia, R.; Rhou, H. Pregnancy after renal transplantation: Effects on mother, child, and renal graft function. Saudi J. Kidney Dis. Transpl. 2016, 27, 227–232. [Google Scholar] [CrossRef] [PubMed]
  156. Choi, J.Y.; Kwon, O.J.; Kang, C.M. The effect of donor-recipient relationship on long-term outcomes of living related donor renal transplantation. Transplant. Proc. 2012, 44, 257–260. [Google Scholar] [CrossRef] [PubMed]
  157. Xu, L.; Han, P.; Liu, Y.; Wang, H.; Yang, Y.; Qiu, F.; Peng, W.; Tang, L.; Fu, J.; Zhu, X.; et al. Study on the effect of kidney transplantation on the health of the patients’ offspring: A report on 252 Chinese children. Cell Biochem. Biophys. 2014, 68, 173–179. [Google Scholar] [CrossRef] [PubMed]
Figure 1. The different “small babies”: Growth curve of small, small for gestational age (SGA), intrauterine growth restricted (IUGR) babies (Y axis: weight and reference curves; X axis: gestational weeks). Legend: (A) is a very small, early preterm normal for gestational age child; (B) is a very small, early preterm, SGA but harmoniously grown, preterm child (mother and father also of small body size); child (C) is a small, SGA, preterm child with a flattening of the growth curve. Although (B,C) are identified also as IUGR, flattening of the growth curve may have a different (unfavorable) meaning as for life-long complications. (Courtesy of R. Attini and P. Gaiotti).
Figure 1. The different “small babies”: Growth curve of small, small for gestational age (SGA), intrauterine growth restricted (IUGR) babies (Y axis: weight and reference curves; X axis: gestational weeks). Legend: (A) is a very small, early preterm normal for gestational age child; (B) is a very small, early preterm, SGA but harmoniously grown, preterm child (mother and father also of small body size); child (C) is a small, SGA, preterm child with a flattening of the growth curve. Although (B,C) are identified also as IUGR, flattening of the growth curve may have a different (unfavorable) meaning as for life-long complications. (Courtesy of R. Attini and P. Gaiotti).
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Table 1. Clinical features affecting pregnancy-related risks in CKD patients.
Table 1. Clinical features affecting pregnancy-related risks in CKD patients.
Clinical FeatureEffect on PregnancyEffect on Maternal Health
CKD stageIncrease across stages (from stage 1 to stage 5) of preterm delivery, caesarean section, SGAIncrease in risk of kidney function impairment, development of hypertension, and proteinuria
Immunologic diseasesPE risk may be increased at least in some diseases (IgAGN, SLE); differential diagnosis with flares may be difficult In CKD, maternal deaths are mainly described in SLE nephropathy (immunologic flares)
Diabetes and diabetic nephropathyIncreased risk in malformations, linked to diabetes, proportional to diabetes controlSame as CKD
Baseline hypertension May be associated with a higher risk of preterm or SGA babiesRisk of kidney function impairment may be increased
Baseline proteinuriaMay be associated with a higher risk of preterm or SGA babiesRisk of kidney function impairment and of persistent hypertension may be increased
CKD: chronic kidney disease; IgAGN: IgA nephropathy; SLE: systemic lupus erythematous; SGA: small for gestational age baby.
Table 2. Adverse pregnancy outcomes in CKD patients and in their offspring [13].
Table 2. Adverse pregnancy outcomes in CKD patients and in their offspring [13].
TermDefinitionMain Issues in CKD
Maternal deathDeath in pregnancy or within 1 week–1 month postpartumToo rare to be quantified, at least in highly resourced settings, where cases are in the setting of severe flares of immunologic diseases (SLE in primis).
CKD progressionDecrease in GFR, rise in sCr, shift to a higher CKD stageDifferently assessed and estimated; may be linked to obstetric policy (anticipating delivery in the case of worsening of the kidney function); 20% and 80% in advanced CKD. Probably not increased in early CKD (stages 1–3a).
Immunologic flares and neonatal SLEFlares of immunologic diseases in pregnancyRisks are mainly but not exclusively limited to patients who start pregnancy with active disease or recent flare-up. Definition of a “safe” zone is not agreed; in quiescent, well-controlled diseases are probably equivalent to nonpregnant, carefully-matched controls.
Transplant rejection (kidney)Acute rejection in pregnancyKidney rejection episodes are not increased with respect to matched controls; may be an issue in unplanned pregnancies.
Abortion Foetal loss, before 21–24 gestational weeksScant data on advanced CKD. An issue in immunologic diseases (not exclusively linked to LLAC) and in diabetic nephropathy.
Stillbirth Delivery of a nonviable infant, after 21–24 gestational weeks Probably not increased in early CKD, too few data in late CKD stages; may be an issue in dialysis patients; when not linked to extreme prematurity, may be specifically linked to SLE, immunologic diseases, and diabetic nephropathy.
Perinatal deathDeath within 1 week–1 month from deliveryUsually a result of extreme prematurity, which bears a risk of respiratory distress, neonatal sepsis, cerebral haemorrhage.
Small, very small babyA baby weighing <1500–2500 g at birth Gestational age adjusted weight may be a better risk marker; however, very low birth weight may bear risks for future health, even without SGA. Different cut-points are used, the most common are 1500 for very small and 2500 for small baby.
Preterm, early extremely preterm Delivery before 37, 32, or 34; 28 completed gestational weeksRisk of preterm delivery increases across CKD stages. Definition of preterm and extremely preterm are agreed (<37 and <28 weeks, respectively); two cut-points are used for early preterm (<32 and <34 weeks)
Small for gestational age (SGA)<5th or <10th centile for gestational ageSGA and IUGR may be associated, but IUGR is also a dynamic event, characterised by flattening of the growth curve. Both are better defined when several data in pregnancy are available.
Intrauterine growth restriction (IUGR)<5th centile or flattening of the growth curveSmall, SGA, and IUGR babies are at higher risk of developing hypertension, metabolic syndrome, and CKD in adulthood.
Malformations Any kind of malformationsMalformations are not increased in the absence of teratogen drugs; exception is diabetic nephropathy (increase in malformations attributed to diabetes); hereditary diseases may not be evident at birth.
Hereditary kidney diseasesAny kind of CKD Several forms of CKD have a hereditary pattern or predisposition, among them, ADPKD, Alport’s, vescico ureteral reflux and CAKUT, IgA, kidney tubular disorders, and mitochondrial diseases.
CKD-hypertensionHigher risk of hypertension and CKD in adulthoodLower nephron number in preterm babies; the risks are probably higher in SGA–IUGR babies than in preterm babies adequate for gestational age.
Other long-term issuesDevelopmental disordersCerebral haemorrhage or neonatal sepsis, not specific of CKD, are a threat in all preterm babies.
CKD: chronic kidney disease; ADPKD: autosomal dominant polycystic kidney disease; CAKUT: complex anomalies of the kidney and of the urinary tract; SLE: systemic lupus erythematous; LLAC: lupus-like anticoagulant; SGA: small for gestational age baby; IUGR: intrauterine growth restriction; GFR glomerular filtration rate; MMF: mycophenolic acid; ACEi: angiotensin-converting enzyme inhibitors; ARBS: angiotensin receptor blockers.
Table 3. The differential diagnosis of disorders associated with AKI and thrombocytopenia in pregnancy (modified from 70).
Table 3. The differential diagnosis of disorders associated with AKI and thrombocytopenia in pregnancy (modified from 70).
Pre-Eclampsia/HELLPHemolytic Uremic Syndrome (HUS)Thrombotic Thrombocytopenic Purpura (TTP)
Usual time of onsetAfter 20 gestational weekspostpartum2nd and 3rd trimester
Arterial hypertension+++++
Renal failure+ (mainly in HELLP)++++
Renal prognosisRecovery75% ESRDUsually good
Neurological impairment+ ++++
Hemolytic anemia++ (HELLP)++++++
Low platelet count+++ (HELLP)++++++
Intravascular coagulation +Usually absent++
Proteinuria++++Rare
Abnormal liver function tests+++ (HELLP)Usually absentUsually absent
Complement alternative pathway activation+ (HELLP)+++Usually absent
Reduced ADAMTS13+Usually absent+++
TreatmentSupportive treatmentPlasmapheresis; plasma infusion
Anti-MAC antibodies
Plasmapheresis; plasma infusion
Anti-CD20 antibodies
HELLP: hemolysis, elevated liver enzymes, low platelets. + present; ++ frequent and severe; +++ very frequent and severe.
Table 4. Challenges for the diagnosis of kidney diseases in pregnancy.
Table 4. Challenges for the diagnosis of kidney diseases in pregnancy.
Sign or SymptomInterference in PregnancyPotential Correction
HypertensionBlood pressure is physiologically reduced, particularly in the 1st trimester; mild–moderate hypertension may be masked by the physiologic changes in early pregnancy.Attention to “high normal” BP; strict monitoring in presence of risk factors (obesity, diabetes, family history, age, CKD); if associated with proteinuria, interference in PE diagnosis.
Kidney function reductionKidney function physiologically increased, in particular in 1st–2nd trimester; CKD stages 2–3 may be missed, in particular if reference eGFR of nonpregnant women is employed.Lack of hyperfiltration is a potential sign of initial reduction of kidney function; “normal” values outside pregnancy should be interpreted with caution in pregnancy.
HematuriaPresence of contaminant RBCs in the urine is common and microhematuria may be misinterpreted as of gynaecologic origin. Possible underestimation in polyuria.Microscopic examination, search for urinary casts, and attention to correct sampling avoid missing this sign pointing to a glomerular origin (most frequent, IgA nephropathy).
ProteinuriaThe physiologic limit is increased to 300 mg/day. Proteinuria may show day-to-day and circadian variations. If assessed on spot urine collection, mild proteinuria may be missed in patients with polyuria.Repeated tests and 24 h urine assessment in cases with trace proteinuria may avoid missing low-grade (albeit clinically relevant) proteinuria.
Tubular derangementsThe usual workout of physiologic pregnancy includes the major ions (Na, K, Calcium). Mild hypokalaemia and hyponatremia are common, due to physiologic hemodilution.Tubular derangements may be elusive. Phosphate, Mg, bicarbonate should be controlled in severe hypokalaemia, severe hyponatremia, or unexplained polyuria.
Urinary infectionUrinary infections are common and usually asymptomatic. Several societies suggest at least one urinary culture per trimester. Repeatedly positive urinary cultures suggest performing ultrasounds of the kidney and urinary tract.
CKD: chronic kidney disease; PE: pre-eclampsia; BP: Blood pressure; RBCs: red blood cells. Na: sodium, K: potassium, eGFR: estimated glomerular filtration rate.
Table 5. Some challenges and open questions in the practical management of hemodialysis patients in pregnancy.
Table 5. Some challenges and open questions in the practical management of hemodialysis patients in pregnancy.
ItemIndicationsOpen Issues
Number of sessionsDaily hemodialysis (DHD) is superior to thrice weekly dialysisDHD is differently defined (5–7 sessions/week); no data on adjustment per body size or residual renal function (RRF): urea level should probably guide the choice. Unclear advantage of shorter/more frequent or of longer/less frequent sessions in presence of RRF.
Duration of sessionThe longest, the best, according to the Canadian experienceScattered positive experience with short DHD; difficult to distinguish between effect of frequency and duration. Long-hours dialysis is more effective in removal of middle molecules and phosphate.
Weight lossThe lowest, the best; attention to avoid dehydration and oligoamniosThe evaluation of weight gain remains empiric. Unclear role for bioimpedance, BNP, BP. Unclear role of biomarkers (s-Flt1, PlGF) in diagnosis of PE.
Blood flowLow blood flow (150–250 mL/min) may be reasonable in intensive HDLower blood flow has to be balanced with higher need for anticoagulation. Long-hours dialysis is associated with better removal of middle molecules and compartmentalised toxins: depuration markers alternative to urea are not identified. Hypophosphatemia is often found: subtle deficits of trace metals or vitamins may be relevant; the role of multivitamin supplementation is not clear.
Dialysate flowLow dialysate flow advised in long-hours dialysis (300 mL/min)
Dialysis efficiencyThe most common target is “near normal” urea (10–15 umol/L) following the day break
Dialysis membraneBiocompatible membranesNo study addressed to different membranes; low-flux membranes limit nutrient loss; high-flux membranes increase middle molecules clearance, but increase also nutrient loss and may induce back-filtration.
CKD: chronic kidney disease; PE: pre-eclampsia; BP: blood pressure; BNP: brain natriuretic peptide; HD: haemodialysis; DHD: daily haemodialysis; s-Flt1: soluble fms like tyrosine kinase 1; PlGF: placental growth factor; RRF: residual renal function.

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MDPI and ACS Style

Piccoli, G.B.; Zakharova, E.; Attini, R.; Ibarra Hernandez, M.; Orozco Guillien, A.; Alrukhaimi, M.; Liu, Z.-H.; Ashuntantang, G.; Covella, B.; Cabiddu, G.; et al. Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases. J. Clin. Med. 2018, 7, 415. https://doi.org/10.3390/jcm7110415

AMA Style

Piccoli GB, Zakharova E, Attini R, Ibarra Hernandez M, Orozco Guillien A, Alrukhaimi M, Liu Z-H, Ashuntantang G, Covella B, Cabiddu G, et al. Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases. Journal of Clinical Medicine. 2018; 7(11):415. https://doi.org/10.3390/jcm7110415

Chicago/Turabian Style

Piccoli, Giorgina B., Elena Zakharova, Rossella Attini, Margarita Ibarra Hernandez, Alejandra Orozco Guillien, Mona Alrukhaimi, Zhi-Hong Liu, Gloria Ashuntantang, Bianca Covella, Gianfranca Cabiddu, and et al. 2018. "Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases" Journal of Clinical Medicine 7, no. 11: 415. https://doi.org/10.3390/jcm7110415

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