Successful pregnancy after protective hemodialysis for chronic kidney disease: A case report.

BACKGROUND: Chronic kidney disease (CKD) affects almost 3% of females of child-bearing age, who have a high risk of adverse maternal and fetal outcomes. Additionally, high renal burden as a result of pregnancy may lead to deterioration of renal function. An increasing number of women with CKD stages 3 to 5 have a strong desire to conceive, and both obstetricians and nephrologists are faced with enormous challenges in terms of their treatment and management. CASE SUMMARY: The case of a 35-year-old pregnant woman with a 10-year history of mild mesangial proliferative glomerulonephritis is described here. CKD progressed from stage 3 to stage 5 rapidly during pregnancy, and protective hemodialysis was started at 28 wk of gestation. Due to preeclampsia at 34 wk of gestation, cesarean section was performed and a healthy baby was delivered. Hemodialysis was discontinued at 4 wk postpartum. After 1 year of follow-up, her renal function was stable, and her baby exhibited good growth and development. CONCLUSION: Protective hemodialysis during pregnancy can prolong gestational age and improve maternal and fetal outcomes in women with advanced CKD.

Trends and characteristics in pre-hospital emergency care in Beijing from 2008 to 2017.

BACKGROUND: We aimed to describe and analyze the pre-hospital emergency medical service (EMS) in Beijing and provide information for the government and medical institutions to optimize EMS. METHODS: We collected all pre-hospital emergency data in Beijing from 2008 to 2017. The chief complaint in each case was classified according to the Medical Priority Dispatch System (MPDS). The sites' administrative districts were determined through geo-encoding of addresses and then classified into four functional regions. We analyzed the demand for EMS, emergency response times (ERT), and disease spectrum for Beijing as a whole, and for each functional region. RESULTS: A total of 4,192,870 pre-hospital EMS cases met the inclusion criteria, with a significant increase (P < 0.001) of 51.60% from 2008 to 2017. EMS demand was positively associated with population (r = 0.946, P < 0.001). The pre-hospital EMS demand rate was 1907.05 in 2008 and 2172.23 in 2017 per 100,000, with no significant change (P = 0.57). ERT increased significantly (P = 0.001), from 19.18 min in 2008 to 24.51 min in 2016. According to MPDS classifications, the demand for pre-hospital care increased for 14 diseases, remained stable for 19, and decreased for only 1 disease. Cases of injury-related disease increased significantly from approximately 90,000 in 2017, accounting for 20% of all pre-hospital EMS cases, and the demand rate decreased in the core region but increased in the sub-urban regions. Cases of heart problems and stroke/transient ischemic attack also increased significantly in the four functional regions, with the highest demand rate in the Core Functional Region. CONCLUSIONS: More resources and effort should be devoted to pre-hospital EMS according to the increased pre-hospital EMS demand and prolonged ERT in Beijing over our 10-year study period. Changes in disease spectrum and differences between functional regions should also be considered.

Dysregulation of complement system during pregnancy in patients with preeclampsia: A prospective study.

Recent studies have shown that aberrant activation of the complement system plays an important role in the pathogenesis of preeclampsia. There is evidence to suggest that aberrant activation of the complement system may already be present during the first trimester. Here, we performed a prospective study in which peripheral blood samples were collected from 500 women during pregnancy. Twenty-one patients (41 specimens) suffering from preeclampsia later in pregnancy were classified into the study group, and sixty-three gravidas with normal pregnancies (136 specimens) were selected as the control group. The plasma concentrations of complement factor B (CFB), C1q, complement factor H (CFH), C3c, C4, C3a, C5a and soluble C5b-9 (sC5b-9) were measured. The levels of CFB (P = 0.004), CFH (P = 0.002), C1q (P = 0.044), C3c (P = 0.032) and C4 (P = 0.015) were significantly higher in preeclampsia than in normal pregnancy during the first trimester, and these levels became similar to those in normal pregnancy thereafter. Before the onset of preeclampsia, the levels of C3a, C5a and sC5b-9 in the preeclampsia group were similar to those in control group even in late pregnancy. C3a levels showed a significant positive correlation with C5a in normal pregnancy (r=0.658, P<0.01) but not in preeclampsia (r = 0.001, P = 1).Thus, we found that aberrant activation of the complement system in patients with preeclampsia was initiated during the first trimester but returned to normal pregnancy levels in the second trimester. At the same time, there is aberrant regulation of complement activation at the C3a-C5a level in preeclampsia during pregnancy.

Membranous Nephropathy in Pregnancy.

BACKGROUND: Primary membranous nephropathy (pMN) is less common in women of child-bearing age. The kidney risk factors to adverse maternal-fetal outcomes and the effects of pregnancy on pMN process need to be investigated. METHODS: We retrospectively screened all the patients with biopsy-proven pMN from 2008 to 2018. Any cases of pregnancy that occurred at the time of pMN diagnosis or during follow-up were included in the study. Clinical and pathological data were collected from all patients at the time of kidney biopsy and their gestational results were recorded. RESULTS: Of the 27 pregnancies with gestational time of 35.9 ± 4.5 weeks, 10 adverse maternal-fetal events occurred, including fetal loss (11%), preterm delivery (26%), and severe preeclampsia (15%). The kidney parameters were relatively stable with all preserved kidney function. Time-averaged urinary protein (p < 0.001) and serum albumin (p < 0.001), maximum urinary protein (p = 0.001) and minimum serum albumin (p = 0.01) before week 20, anti-phospholipase A2 receptor (PLA2R) positivity (p = 0.03), and no remission during pregnancy (p = 0.004) were risk factors to adverse maternal-fetal outcomes. Time-averaged urinary protein and serum albumin correlated with the birth weight percentile of neonates. CONCLUSIONS: Pregnancy in pMN patients showed risks to adverse maternal-fetal events. Heavy proteinuria, especially before week 20 of gestation, severe hypoalbuminemia, positive anti-PLA2R, and no remission were risk factors to worse outcomes.

Normal range of complement components during pregnancy: A prospective study.

PROBLEM: The complement system plays a key role in normal placentation, and delicate regulation of complement system activation is critical for successful pregnancy. Therefore, establishing a normal range of complement components during pregnancy is important for clinical evaluation and research. METHODS: We performed a prospective study to investigate the normal range of complement components in circulation during different stages of pregnancy. Plasma concentrations of complement factor B (CFB), C1q, complement factor H (CFH), C3, C3c, and C4 were measured using an immunoturbidimetric assay; mannan-binding lectin (MBL), C3a, C5a, and soluble C5b-9 (sC5b-9) levels at different time points of pregnancy were determined by enzyme-linked immunosorbent assay (ELISA). RESULTS: A total of 733 plasma samples were collected from 362 women with a normal pregnancy and 65 samples from non-pregnant women. In the first trimester of pregnancy, the levels of CFB, CFH, MBL, C3c, C4, and C3a were 414.5 ± 85.9 mg/L (95% CI for mean: 402.4-426.6 mg/L), 381.0 ± 89.0 mg/L (95% CI for mean: 368.5-393.6 mg/L), 4274.5 ± 2752 ng/mL (95% CI for mean: 3881.1-4656.4 ng/mL), 1346.9 ± 419.8 mg/L (95% CI for mean: 1287.7-1406.0 mg/L), 357.4 ± 101.8 mg/L (95% CI for mean: 343.0-371.7 mg/L), and 182.5 ± 150.0 ng/mL (95% CI for mean: 186.9-229.1 ng/mL), respectively. The levels of C3 and C4 increased gradually throughout pregnancy. The levels of C1q, C5a, and sC5b-9 in the first and second trimesters were nearly the same as those in non-pregnant women. CONCLUSION: The results of this study show that pregnancy itself may influence the plasma levels of complement system components.

Overactivation of Complement Alternative Pathway in Postpartum Atypical Hemolytic Uremic Syndrome Patients with Renal Involvement.

PROBLEM: Postpartum atypical hemolytic uremic syndrome (aHUS) is a life-threatening syndrome with unclear pathogenesis. The current study aimed to investigate the clinical and pathological features, complement activation status, and the genetic variations in a Chinese cohort of patients with renal biopsy-proven postpartum aHUS. METHOD OF STUDY: Five patients with postpartum aHUS were recruited. Renal biopsy specimens were examined and scored. Plasma levels of complements were detected, and coding sequences of complement regulators were screened. Anti-CFH/CFI autoantibodies were further detected. RESULTS: Patients with postpartum aHUS patients presented with severe clinical manifestations and renal involvement. The renal biopsies of the five patients showed typical features of thrombotic microangiopathies. The levels of the following complement components, C4d, Bb, C3a, C5a, and SC5b-9, were significantly elevated in patients with postpartum aHUS compared with normal non-pregnant controls. The plasma levels of CFH and CFI significantly decreased in patients with postpartum aHUS compared with normal pregnant women. Three CFH single nucleotide polymorphisms (SNPs) were identified in the five patients. Two patients presented with CFH autoantibodies. CONCLUSION: Postpartum aHUS is a clinical syndrome with severe renal damage. Genetic deficiencies and autoantibodies of CFH may lead to alternative pathway overactivation and participated in the pathogenesis of postpartum aHUS.

[Expression of various subtypes of human leukocyte antigen-G in placenta of patients complicated with severe pre-eclampsia].

OBJECTIVE: To investigate the different expression of various subtypes of human leukocyte antigen-G (HLA-G) in placenta of patients complicated with severe pre-eclampsia. METHODS: Ten placental samples from early-onset severe pre-eclamptic pregnancies and ten from late-onset severe pre-eclamptic pregnancies were collected as study group; ten placental samples from preterm pregnancies and ten from normal pregnancies were collected as control group. The levels of HLA-G protein in the four groups were measured by western blot and immunohistochemistry. RESULTS: (1) HLA-G1 protein decreased significantly in both the early-onset (2.4 ± 0.6 versus 2.9 ± 1.1, P < 0.05) and the late-onset pre-eclampsia groups (3.5 ± 2.1 versus 4.2 ± 2.4, P < 0.05). (2) HLA-G5 protein increased in the late-onset pre-eclampsia groups (1.8 ± 1.1 versus 1.1 ± 0.9, P < 0.05); the increase in the early-onset pre-eclampsia group is not obvious (1.6 ± 0.9 versus 1.4 ± 0.7, P > 0.05). (3) The level of HLA-G1 protein in placenta from patients complicated with premature labor is lower (2.9 ± 1.1 versus 4.2 ± 2.4, P < 0.05); HLA-G5 protein does not change significantly (1.4 ± 0.7 versus 1.1 ± 0.9, P > 0.05). (4) HLA-G1 and G5 proteins mainly express in the placenta extravillous cytotrophoblast cells. There is also a high level of expression around the blood vessels and in the extraembryonic mesoderm. CONCLUSIONS: (1) HLA-G1 decreased significantly in both the early-onset and late-onset pre-eclamptic patients. (2) HLA-G5 increased in both the early-onset and late-onset pre-eclamptic patients, and the increase in the late-onset pre-eclamptic patients is obvious. (3) In late pregnancy, the level of HLA-G1 is lower in patients complicated with premature labor, this may be the result of its earlier pregnancy week; HLA-G5 does not change significantly. (4) HLA-G1 and G5 mainly express in the placenta extravillous cytotrophoblast cells.

[Effects of gestational age on perinatal outcomes in patients complicated with early onset severe preeclampsia].

OBJECTIVE: To analysis the relationship between gestational age and perinatal outcomes in patients complicated with early onset severe preeclampsia. METHODS: Retrospective study was conducted on clinical documents of 221 patients with early onset severe preeclampsia (< 34 weeks) who delivered after 28 gestational weeks in Peking University First Hospital from July 1999 to June 2009. Patients were divided into three groups based on gestational weeks at delivery: group I (n = 81) delivered at 28 - 31 weeks(+6), group II (n = 78) at 32 - 33 weeks(+6) and group III (n = 62) after 34 weeks. The clinical characteristics and perinatal outcomes were compared among those three groups. RESULTS: (1) Outcome of neonates: Among 221 neonates, 13 neonates lost follow-up, including 9 in group I, 3 in group II, 1 in group III. The incidence of neonatal respiratory distress syndrome (RDS) of 26% (19/72) in group I were significantly higher than 7% (5/75) in group II and 10% (6/61) in group III (P < 0.05). The neonatal mortality rate of (43%, 31/72) in group I were significantly higher than 3% (2/61) in group III and 28% (21/75) in group II (P < 0.05). The incidence of maternal complications showed no statistical difference among three groups. (2) Neonatal death analysis: all neonatal death were due to parents' give up, including 26% (8/31) in group I, 67% (14/21) in group II and 1/2 in group III, which reached statistical difference (P < 0.05). CONCLUSIONS: The incidence of neonatal RDS in mother with early onset severe preeclampsia was decreased if delivered after 32 weeks, and the perinatal mortality was remarkably decreased if delivered after 34 weeks. Therefore, the perinatal survival rate in women with early onset severe preeclampsia can be improved by minimizing the impact of social factors.