Kidney biopsy during pregnancy: a difficult decision. A case series reporting on 20 patients from Mexico.

BACKGROUND: Kidney biopsy is a routine procedure in the diagnosis of kidney disease, but during pregnancy it carries potential adverse effects for both mother and child, aside from the challenges of obtaining adequate tissue samples. Nevertheless, a precise diagnosis is necessary when specific and potentially toxic treatments are to be used during pregnancy. The present report presents our experience with regard to the usefulness and safety of kidney biopsies during pregnancy. METHODS: Retrospective analysis of clinical indications, complications, histopathological diagnoses, and treatment of patients who had kidney biopsies done at a single academic center during gestation weeks 11-30 between January 2015 and January 2019. RESULTS: Kidney biopsies were carried out in 20 pregnant patients with nephrotic proteinuria. Biopsy was adequate in all patients. The histological diagnoses included focal segmental glomerulosclerosis (collapsing, tip and perihiliar varieties), membranous lupus nephropathy, diabetic nephropathy, and IgA nephropathy. Treatment was associated with reduction of proteinuria in 17 patients and reduction of serum creatinine in 9 out of 11 patients who had serum creatinine ≥ 1 mg/dl at the time of biopsy. There was one major bleeding complication that required transfusion of one unit of blood. There was a high incidence of preeclampsia, preterm delivery, and low birth weight despite appropriate kidney disease therapy. CONCLUSIONS: Kidney biopsy may be done during pregnancy when therapeutic decisions depend on a precise pathologic diagnosis.

Systemic lupus erythematosus and pregnancy: Strategies before, during and after pregnancy to improve outcomes / Lupus eritematoso sistémico y embarazo: estrategias antes, durante y después del embarazo para mejorar los desenlaces

ABSTRACT Systemic lupus erythematosus is a multisystemic autoimmune disorder that predominantly affects women in reproductive years. Pregnancy in women with SLE is still considered a high-risk condition although several strategies may improve maternal and fetal outcomes. Preconception counseling is fundamental and should include identification of risk factors for adverse pregnancy outcomes, explanation of potential maternal and obstetric complications and timely planning of pregnancy. Risk stratification must consider end-organ damage, comorbidities, disease activity and autoantibodies profile in order to implement an individual-risk pregnancy monitoring plan by a multidisciplinary team. Hydroxychloroquine and low dose aspirin have shown to lower the risk of disease flares and preeclampsia with a good safety profile, so its use during pregnancy in all SLE patients is recommended. Lupus nephritis and preeclampsia share clinical and laboratory features hindering differentiation between both entities. Novel angiogenic markers and fetal ultrasound findings could be helpful in the differential diagnosis, especially after 20 weeks of gestation. Antiphospholipid antibodies, particularly lupus anticoagulant, are closely associated with obstetric complications. Therapy with low dose aspirin and heparin, according to risk profile, may improve live birth rates. Anti-Ro/La antibodies confer risk for neonatal lupus, and therefore preventive therapy and special fetal surveillance should be instituted.

RESUMEN El lupus eritematoso sistémico es un trastorno autoinmune multisistémico que afecta primordialmente a mujeres en edad reproductiva. El embarazo en mujeres con LES aún se considera una condición de alto riesgo, a pesar de que diversas estrategias pueden mejorar los desenlaces maternos y fetales. La asesoría preconcepción es fundamental, y debe incluir la identificación de factores de riesgo de desenlaces adversos del embarazo, una explicación de las posibles complicaciones maternas y obstétricas, así como la planificación oportuna del embarazo. La estratificación de riesgos debe considerar el daño orgánico terminal, las comorbilidades, la actividad de la enfermedad y el perfil de autoanticuerpos, a fin de llevar a cabo un plan de monitoreo de los riesgos individuales del embarazo por parte de un equipo multidisciplinario. La hidroxicloroquina y la aspirina a bajas dosis han demostrado reducir el riesgo de exacerbaciones de la enfermedad y de preeclampsia, con un buen perfil de seguridad, por lo cual se recomienda su uso en todas las pacientes con LES durante el embarazo. La nefritis lúpica y la preeclampsia comparten características clínicas y de laboratorio, obstaculizando la diferenciación entre las 2 entidades. Nuevos marcadores angiogénicos y hallazgos ecográficos fetales pudieran ser de utilidad para el diagnóstico diferencial, especialmente después de las 20 semanas de gestación. Los anticuerpos antifosfolípidos, en particular el anticoagulante lúpico, tiene una estrecha asociación con las complicaciones obstétricas. El tratamiento con aspirina a bajas dosis y heparina, según el perfil de riesgos, puede mejorar las tasas de nacimientos vivos. Los anticuerpos anti-Ro/La representan un riesgo de lupus neonatal, por lo cual debe instituirse tratamiento preventivo y vigilancia fetal especial.

Collapsing Lesions and Focal Segmental Glomerulosclerosis in Pregnancy: A Report of 3 Cases.

The relationship between focal segmental glomerulosclerosis (FSGS) and pregnancy is complex and not completely elucidated. Pregnancy in patients with FSGS poses a high risk for complications, possibly due to hemodynamic factors, imbalance between angiogenic and antiangiogenic factors, and hormonal conditioning. Although poor clinical outcomes associated with collapsing FSGS are common outside of pregnancy, the prognosis during pregnancy is not well documented. We report 3 patients who developed collapsing FSGS during pregnancy, 2 of whom had presumed underlying FSGS. Two patients underwent biopsy during pregnancy, and 1, during the puerperium. None of the 3 patients improved spontaneously after delivery, and 1 experienced a rapid deterioration in kidney function and proteinuria after delivery. Aggressive immunosuppressive therapy led to a full response in 1 case (without chronic lesions) and to partial responses in the remaining 2 cases. These cases suggest that collapsing lesions should be considered in patients with FSGS who develop a rapid increase in serum creatinine level or proteinuria during pregnancy and that these lesions may at least partially respond to treatment.

Acute kidney injury in pregnancy and the role of underlying CKD: a point of view from México.

The incidence of acute kidney injury in pregnancy (P-AKI) in developed countries is significantly lower than in developing ones, where it is estimated to range between 4 and 26%. Mortality in cases of P-AKI requiring dialysis is high, varying from 20 to 80%. In developing countries, clinical decisions are often based on the availability of services and not on needs. Prenatal surveillance in Mexico does not include serum creatinine, limiting the potential for early diagnosis of AKI and CKD and their differential diagnosis. There are few specialized centers for the care of a pregnancy complicated with kidney disease in Mexico. P-AKI superimposed on preexistent, and usually undiagnosed CKD, is common: in Guadalajara 10 out of the 27 patients with Stage 3-5 CKD or nephrotic proteinuria, that were followed in 2013-2015, required renal replacement therapy (RRT) in pregnancy; in the same period in Mexico City out of 18 patients with P-AKI requiring dialysis, 5 remained dialysis dependent, 3 started dialysis in the following year after their pregnancy and only 1 fully recovered renal function. The grim prognosis is exacerbated by the fact that 70% of Mexicans are not reimbursed for dialysis, and pregnancy-related coverage lasts for only 42 days after delivery. Perinatal results are no less troubling, as most patients with P-AKI give birth preterm to small or very small babies. While our data do not allow us to evaluate needs, they do make it possible to define the complexity of the problems faced in the care of P-AKI in Mexico. Early diagnosis of P-AKI and chronic kidney disease (CKD) is needed to protect mothers and children and the country urgently needs programs to enable it to fulfil the World Health Organization's imperative that we "make every mother and child count".