Successful Fetal and Maternal Pregnancy Outcomes in a Woman with Pre-Existing Advanced Chronic Kidney Disease in a Low-Income Setting: case report

Pregnancy in women with pre-existing Chronic Kidney Disease (CKD) is an important risk factor for early and late maternal and fetal morbidity and mortality. The outcomes are especially worse in low-income settings. We present a case of successful pregnancy in a 28-year-old woman with CKD secondary to ischaemic renal disease. Pregnant women with CKD are among the high-risk populations for adverse fetal and maternal outcomes [1] are usually managed in liaison with nephrologists. Chronic kidney disease is rare in pregnancy [2] and this has been attributed to the following reasons: most pregnant women are young and healthy; many women with advanced CKD are either middle-aged/elderly or are infertile; and renal function tests are not routinely done in pregnant women [3]. Although pregnancy is safer in CKD women who have stages 1 and 2 CKD, in addition to controlled hypertension and proteinuria, achieving a successful maternal and fetal outcome in low-income setting is a rarity and will require adequate monitoring of pregnant women with underlying renal diseases from different aetiologies [1].The learning point is that women with pre-existing advanced CKD who desire to conceive should undergo preconception counselling and care by the nephrologists and obstetricians. Their Blood Pressure (BP) should be well controlled for a sustained period prior to conception. Furthermore, intensive multidisciplinary monitoring is required during the pregnancy in order to achieve optimal pregnancy outcomes for the mother and fetus.

A 28-year-old Nigerian woman, who was diagnosed of hypertension and CKD secondary to ischaemic renal disease after her second pregnancy, presented at the renal clinic at 24 weeks gestation of her third pregnancy.  She was on follow up at the renal clinic for one year before the index pregnancy and had preconception ccounselling.  She was Gravida - 3, Parity - 2 (G3P2) with one living child. At this visit, she was asymptomatic. She had no complaints of abnormal body swelling, dyspnea, oliguria, or uremic symptoms. Her pulse rate was 86 beats per minute while her blood pressure (BP) was 114/80 mmHg. All peripheral pulses were present. Symphysio-Fundal height was 26 cm. Other aspects of physical examination were normal. Her dipstick urinalysis showed pH of 6 and 1+ protein, other urine test strip parameters were normal; urine albumin creatinine ratio (uACR) was 37.4 mg/g; Packed cell volume was 0.33 l/l and serum creatinine were 130 µmol/L (eGFR = 50 ml/min/1.73m²).  

During this visit she was counselled on the delicate nature of the pregnancy and the importance of strict compliance with renal and antenatal clinic attendance. She was monitored at fortnightly intervals at both renal and antenatal clinics. She was placed on fesolate 200mg thrice a day, folic acid 5 mg daily and acetylsalicylic acid 75 mg daily throughout the pregnancy period. Meanwhile at the renal clinic, her BP, proteinuria and renal function were intensively monitored. Her antihypertensives (lisinopril 10 mg and amlodipine 5 mg) were stopped when her pregnancy was confirmed and she maintained normal blood pressure for the duration of the pregnancy. She successfully delivered a female baby who weighed 2.9 kg via elective caesarean section at 38 weeks gestational age. The postpartum period was uneventful and she was discharged to the outpatient clinic on the 4^th day post-operation. During her follow up clinic visit at six weeks postpartum, her BP was persistently elevated (170/110 mmHg) and she was commenced on tablet amlodipine 10 mg daily and tablet alpha methyldopa 250 mg twice a day. Subsequently her BP had remained under control with anti-hypertensives up till her last visit at 3 months postpartum. Available investigations at 3 months postpartum showed 2 + of protein, PCV of 38 l/l, serum creatinine of 110 µmol/L (Table 1) and BP of 120/80 mmHg.  She was counselled on contraception and the need to plan future pregnancies with her nephrologists and obstetricians.  

Table 1: Serial serum electrolyte, urea and creatinine of the patient during the index (3rd) pregnancy and postpartum period. 

Her first pregnancy was booked outside a teaching hospital. She was normotensive and had no record of kidney function tests. Pregnancy was carried to term without any comorbidities and delivery was complicated by a male dead fetus and postpartum hemorrhage. The second pregnancy was booked at a teaching hospital at gestational age of 30 weeks. She had an unfavourable cervix at term that necessitated induction of labor. She was delivered via emergency caesarean section on account of failed induction of labor. Two days after surgery, her urine output sharply reduced to 370 millilitres in 24 hours despite receiving 2.2 litres over the same period. Additionally, her serum creatinine, which was 104 micromol per litre (µmol/l) (eGFR = 65 ml/min/1.73m²), had risen to 174 µmol/l (eGFR = 35 ml/min/1.73m²) two days after surgery. On the third day post - surgery, her serum creatinine was 558 µmol/L (eGFR = 9 ml/min/1.73m²). An abdominopelvic ultrasound scan did not show any evidence of hydronephrosis or ureteral injuries. On account of this, a diagnosis of acute kidney injury was made. She subsequently had two sessions of renal replacement therapy which resulted in the resolution of oliguria. Serum creatinine at discharge was 337 µmol/L. During the follow up at the renal clinic after her second confinement, she was diagnosed with CKD 3B A2 secondary to ischaemic renal disease after she was observed to have chronically low estimated glomerular filtration rate (34.5ml/min/1.73m²), persistent proteinuria, increased vascular resistance in the right kidney on Doppler scan (Peak systolic velocities on the right and left kidneys were 36.4 cm/s and 32.5 cm/s respectively, resistive index was 0.7 on the right kidney and 0.65 on the left kidney) and disproportionate kidney sizes >1.5cm on ultrasound (right kidney measured 8.7x2.4 cm, left kidney measured 12.1x4.3 cm, both had increased parenchymal echogenicity, fairly maintained sinoparenchymal differentiation and no calyceal dilatation). She could not afford magnetic resonance angiography due to financial constraints. She was also diagnosed hypertensive in this period and commenced on acetysalycilic acid 75 mg daily, atorvastatin 20 mg at night, amlodipine 5 mg daily and lisinopril 10 mg daily.  Her average Blood Pressure (BP) prior to this presentation was 126/80 mmHg. This BP control was sustained for about a year before our patient became pregnant.

Pregnancy in patients with pre-existing CKD is associated with increased risk of fetal and maternal complications, including prematurity, low birth weight, Intrauterine Fetal Death (IUFD), preeclampsia, eclampsia, deteriorating kidney function and progression to End Stage Kidney Disease (ESKD) [1]. Studies from developed countries have shown that the risk of complications is more prominent in advanced stages of CKD [4]. It is anticipated that the situation would be worse in low-income settings. However, as Maule et al demonstrated in their review, there is dearth of data on the impact of pre-existing CKD on pregnancy outcomes in Africa [5]. Similarly the literature on outcomes among pregnant Nigerians with pre-existing CKD are scarce. We identified two cases after a review of the English-language literature and we compared them to the index case [6,7]. 

In 2013 Okafor et al reported a 24-year-old Nigerian woman who was diagnosed with proteinuric CKD three years before she became pregnant [6]. However she had no preconception care and no nephrologist visits. She was seen at 10 weeks gestation with severely elevated BP which was controlled within seven weeks using methyldopa and nifedipine. Her pregnancy was complicated by eclampsia, IUFD at 21 weeks gestation, and worsening kidney function requiring hemodialysis sessions. This outcome is in stark contrast with our patient who carried her pregnancy to term and delivered a healthy female baby. At onset both patients had hypertension, proteinuria and stage 3 CKD, which are major factors that have been found to increase the risk of poor pregnancy outcomes [2,4]. However our patient was normotensive for a year prior to conception and remained normotensive throughout the pregnancy period whereas the earlier patient was hypertensive until 17 weeks gestation. Thus, the differences in their preconception care could be the main factor that determined their different outcomes. The outcome in our patient also compares favourably to another case reported by Mbamara et al [7]. They reported the case of a 39-year-old woman, previously known to be hypertensive, who presented with poorly controlled BP and CKD stage 5 secondary to autosomal dominant polycystic kidney disease at 32 weeks gestation. She had no preconception care and no nephrologist visits; she eventually delivered a Small-For-Gestational Age (SGA) with rapid deterioration of her kidney function to ESKD. Normal kidney function is of great importance in sustaining a healthy pregnancy [8]. This is because the normal kidneys have to undergo structural and hemodynamic changes during pregnancy in order to maintain homeostasis in the mother and fetus [8,9]. These structural changes include increase in renal size and dilatation of the pelvicalyceal system [8]. Hemodynamically, the renal plasma flow increases in early pregnancy and attains a maximum at 2^nd trimester and thereafter, falls to about 50% above non pregnancy levels in third trimester [8]. The glomerular filtration rate also increases due to the increased renal blood flow [8].The levels of serum creatinine and urea are decreased in pregnancy due to gestational hyper-filtration [9]. Other renal changes in pregnancy include physiological proteinuria up to 300 mg/day, decrease in blood pressure and intravascular volume expansion [8]. These structural and hemodynamic changes in pregnancy are absent or incomplete in women with CKD leading to adverse fetal and maternal outcomes in this population [10]. It has been documented that women with moderate to severe renal function (CKD stages 3 to 5), proteinuria and uncontrolled BP before pregnancy are at greatest risk of an accelerated decline in renal function during pregnancy [2,4,10]. Just as recommended by Williams et al, [9] our patient was managed by a multidisciplinary team which included the obstetrician and nephrologist throughout the antenatal period. Other recommendations which were adhered to by our  patient include regular monitoring of renal function (using serum creatinine and proteinuria), blood pressure and when appropriate ultrasonography should be done to identify pathological changes and allow timely intervention in optimizing perinatal and maternal outcome [9]. Prior to conception, women with CKD should be made aware of the risk to their long term renal function and should be counselled on the need to plan pregnancy when potential risks are minimized [9]. Our patient was counselled on the above measures. Contraceptives should be offered to those who do not wish, or are not yet ready, to conceive [9]. Fetotoxic drugs such as angiotensin receptor blocker or angiotensin converting enzyme inhibitor should be stopped before pregnancy [9]. The appropriate schedule of antenatal visit is every 2 weeks until 24 weeks (alternating between obstetrician and nephrologist) and then weekly until delivery [9]. Although, our  patient did not require anti-hypertensives throughout the pregnancy, safer anti-hypertensives in pregnancy include alpha methyldopa, calcium channel blockers, hydralazine and labetalol [9].

This clinical case highlights successful fetal and maternal outcomes in a pregnant woman with pre-existing advanced CKD and the important role that sustained strict BP control in the preconception period can have on improving pregnancy outcomes in this high-risk population, even in low-income settings. A multidisciplinary specialized team is also integral to the successful management of pregnant women with CKD. Appropriate counselling for pregnancy in CKD women as well as regular antenatal monitoring will guide timely expert intervention in order to achieve an optimal pregnancy outcome and conserve maternal renal function. Early antenatal care booking should be done in a specialized centre where multidisciplinary experts will be involved in the care of pregnant women with CKD.

The authors would like to thank the Department of Medicine, Obstetrics and Gynaecology, Radiology, Pediatrics and Anesthesiology at Nnamdi Azikiwe University Teaching Hospital Nnewi, Nigeria.

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

1. Bartholomew Chukwuka Ozuemba - conception and manuscript writing.
2. Chidozie Ndubisi Ndulue - literature review, manuscript writing and editing.

Written informed consent was obtained from the patient for publication of this case report.

The authors declare that they have no competing interests.

The authors declare that this study has received no financial support.

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