Pregnancies in Women With Kidney Failure on Home Dialysis in the United States.

Introduction: Women with kidney failure have impaired fertility and are at a higher risk of maternal and fetal morbidity and mortality. Little is known about pregnancies in women receiving maintenance home dialysis in the United States. Methods: Using data from the United States Renal Data System (USRDS), a cohort of 26,387 women aged 15 to 49 years with kidney failure receiving maintenance home dialysis from 2005 to 2018 was examined. We calculated pregnancy rates and identified factors, including the modality associated with pregnancy receiving home dialysis. Results: Overall, 437 pregnancies were identified in 26,837 women on home dialysis. The unadjusted pregnancy rate was 8.6 per 1000 person-years (PTPY). The unadjusted pregnancy rate was higher on home hemodialysis (16.0 vs. 7.5 PTPY) than on peritoneal dialysis. Women receiving home hemodialysis had a higher adjusted likelihood of pregnancy than women receiving peritoneal dialysis (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.79-3.05). Compared with women aged 20 to 24 years, the likelihood of pregnancy was lower in women aged 30 to 34 years (HR, 0.64; 95% CI, 0.43-0.96), 35 to 39 years (HR, 0.53; 95% CI, 0.35-0.79), 40 to 44 years (HR, 0.32; 95% CI, 0.21-0.49), and 45 to 49 years (HR, 0.21; 95% CI, 0.13-0.33). Whereas Black women had a higher likelihood of pregnancy (HR, 1.40; 95% CI, 1.07-1.83), there was no difference in likelihood of pregnancy in Asian, Hispanic, and Native Americans as compared to Whites. Body mass index, cause of kidney failure, socioeconomic status, rurality, predialysis nephrology care, or dialysis vintage were not significantly associated with pregnancy on home dialysis. Conclusion: The pregnancy rate in women with kidney failure undergoing home dialysis is higher with home hemodialysis than with peritoneal dialysis. Younger age and Black race or ethnicity are associated with a higher likelihood of pregnancy among women receiving home dialysis. This information can guide clinicians in preconception counselling and making informed treatment decisions for pregnant women on home dialysis.

Contraceptive Use in Females With Advanced CKD: A Qualitative Study.

Rationale & Objective: Pregnancy in females with kidney disease is not uncommon and is associated with adverse maternal and fetal outcomes. The use of contraception in females with chronic kidney disease remains low. We sought to describe the perspectives of female patients with advanced chronic kidney disease on the use of contraception. Study Design: Qualitative study. Setting & Participants: We conducted 5 focus group interviews involving 16 adult female patients with advanced chronic kidney disease (n = 3 nondialysis nontransplant chronic kidney disease, n = 9 kidney transplant, and n = 4 kidney failure receiving dialysis) in the United States, following which thematic saturation was reached. Analytical Approach: Interview transcripts were analyzed thematically. Results: We identified the following 5 themes: 1) variable knowledge regarding reproductive health with kidney disease, 2) inadequate counseling about contraceptive use, 3) lack of interdisciplinary coordination regarding contraceptive use, 4) insufficient educational resources available to guide the contraceptive discussion, and 5) need for research to better understand reproductive needs in females with kidney disease. Limitations: Patients were from a single center in the United States, and the study is limited by the transferability of findings to other settings. Conclusions: Patients with chronic kidney disease report emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Strategies to strengthen these factors may improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease. Plain-Language Summary: Pregnancy in females with kidney disease is common and associated with a higher risk of adverse maternal and fetal outcomes, but the use of contraception remains low. Little is known about female patients' experiences in contraceptive use that may contribute to low contraceptive use in this high-risk population. In the present study using focus group interviews, patients with chronic kidney disease reported emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Interventions are needed to strengthen these factors to improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease.

Evaluation and Management of Hypertensive Disorders of Pregnancy.

Hypertensive disorders of pregnancy complicate up to 10% of pregnancies and remain the major cause of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy can be classified into four groups depending on the onset of hypertension and the presence of target organ involvement: chronic hypertension, preeclampsia, gestational hypertension, and superimposed preeclampsia on chronic hypertension. Hypertension during pregnancy is associated with a higher risk of cardiovascular disease and kidney failure. Early diagnosis and proper treatment for pregnant women with hypertension remain a priority since this leads to improved maternal and fetal outcomes. Labetalol, nifedipine, methyldopa, and hydralazine are the preferred medications to treat hypertension during pregnancy. In this comprehensive review, we discuss the diagnostic criteria, evaluation, and management of pregnant women with hypertension.

Pregnancy-Related Acute Kidney Injury: Do We Know What to Do?

Pregnancy-related AKI is a global health problem and is associated with a higher risk of both maternal and fetal morbidity and mortality. Risk factors for developing AKI during pregnancy include older age, history of preeclampsia, and comorbidities like diabetes. Hyperemesis gravidarum is a common cause of AKI during the first trimester, and conditions such as preeclampsia, acute fatty liver disease of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and placental abruption are important causes of AKI later in the pregnancy. Diagnosis of pregnancy-related AKI is challenging due to the lack of standard criteria and overlap of clinical manifestations among different etiologies. Timely diagnosis of pregnancy-related AKI is instrumental. Specific treatment includes steroids and immunosuppressive therapy for glomerulonephritis, prompt delivery for severe preeclampsia and acute fatty liver of pregnancy, plasmapheresis for thrombotic thrombocytopenic purpura, and eculizumab for the atypical hemolytic uremic syndrome. Due to the high complexity, management of pregnancy-related AKI should be performed by a multidisciplinary team consisting of a nephrologist, obstetrician, and neonatologist.

Contraceptive use among women with kidney transplants in the United States.

BACKGROUND: Kidney transplant improves reproductive function in women with end-stage kidney disease. Little is known about contraceptive use in women with history of kidney transplants. METHODS: Using data from the United States Renal Data System, we evaluated for each calendar year women with kidney transplantation between 1/1/2005 and 12/31/2013 who were aged 15-44 years with Medicare as the primary payer and linked data from the United Network for Organ Sharing, for up to three entire years after the date of transplantation. We determined rates of contraceptive use and used multivariable logistic regression to identify factors associated with contraceptive use. RESULTS: The study cohort included 13,150 women and represented 26,624 person-years. The rate of contraceptive use was 9.5%. Compared to women aged 15-24 years, contraceptive use was lower in women aged 30-34 years (OR 0.67; CI 0.58-0.78), 35-39 years (OR 0.36; CI 0.31-0.43), and 40-44 years (OR 0.23; CI 0.19-0.28). Compared to white women, contraceptive use was higher both in black women (OR 1.26; CI 1.10-1.43) and Native American women (OR 1.52; CI 1.02-2.26). Women had lower rates of contraceptive use in the second-year post-transplant (OR 0.87; CI 0.79-0.94) and the third-year post-transplant (OR0.69; CI 0.62-0.76) than in the first-year post-transplant. Women with a history of diabetes had a lower likelihood of contraceptive use (OR 0.80; CI 0.65-0.99). CONCLUSION: Among women with kidney transplants, contraceptive use remains low at 9.5%. Factors associated with a higher likelihood of contraceptive use include younger age and black and Native American race/ethnicity; and second- and third-year post-transplant. The history of diabetes is associated with a lower likelihood of contraceptive use. The study highlights the need of increasing awareness for safe and effective contraceptive use in women with kidney transplants.

Racial disparities and factors associated with pregnancy in kidney transplant recipients in the United States.

BACKGROUND: Although kidney transplant improves reproductive function in women with end-stage kidney disease (ESKD), pregnancy in kidney transplant recipients' remains challenging due to the risk of adverse maternal and fetal outcomes. METHODS: We evaluated a retrospective cohort of 7,966 women who were aged 15-45 years and received a kidney transplant between January 1, 2005 and December 31, 2011 from the United States Renal Data System with Medicare as the primary payer for the entire three years after the date of transplantation. Unadjusted and adjusted rates of pregnancy in the first three post-transplant years were calculated, using Poisson regression for the adjustment. Factors associated with pregnancy, including race, were examined using logistic regression. RESULTS: Overall, 293 pregnancies were identified in 7966 women. The unadjusted pregnancy rate was 13.8 per thousand person-years (PTPY) (95% confidence interval (CI), 12.3-15.5). Pregnancy rates were roughly constant in the years 2005-2011 except in 2005 and 2010. The rate of pregnancy was highest in Hispanic women (21.4 PTPY; 95% CI, 17.2-26.4) and Hispanic women had a higher likelihood of pregnancy as compared to white women (OR, 1.56; CI, 1.12-2.16). Pregnancy rates were lowest in women aged 30-34 years and 35-45 years at transplant, and women aged 30-34 years and 35-45 years at transplant were less likely to ever become pregnant during the follow-up (odds ratio [OR], 0.69; CI, 0.49-0.98 and OR, 0.14; CI 0.09-0.21 respectively) as compared to women aged 25-29 years at time of transplant. Women had higher rates of pregnancy in the second and third-year post-transplant (16.0 PTPY, CI 13.2-19.2 and 16.9 PTPY, CI 14.0-20.4) than in the first-year post-transplant (9.0 PTPY, CI 7.0-11.4). In transplant recipients, pregnancy was more likely in women with ESKD due to cystic disease (OR, 2.42; CI, 1.02-5.74) or glomerulonephritis (OR, 2.14; CI, 1.07-4.31) as compared to women with ESKD due to diabetes. CONCLUSION: Hispanic race, younger age, and ESKD cause due to cystic disease or glomerulonephritis are significant factors associated with a higher likelihood of pregnancy. Pregnancy rates have been fairly constant over the last decade. This study improves our understanding of factors associated with pregnancy in kidney transplant recipients.

Galectin-3 expression and effect of supplementation in neonatal mice with disseminated Candida albicans infection.

BACKGROUND: Invasive candidiasis is an important cause of fungal infections in immunocompromised patients, including premature infants. The S-type lectin, galectin-3 (gal3), is increasingly recognized for its role in antifungal host defense. This study tested the hypothesis that tissue gal3 expression is affected by disseminated infection with Candida albicans and that supplementation with gal3 will provide a benefit in this setting. METHODS: To determine the expression of gal3 at the tissue level in response to disseminated infection with C. albicans, adult and neonatal mice were infected using previously established models. End points were chosen that reflected substantive tissue fungal burden but before mortality. RESULTS: No differences in gal3 were detected in tissues of adult animals relative to uninfected controls. In neonatal animals, gal3 concentration was lower in the spleen of infected animals compared to uninfected. Pretreatment of neonatal mice with recombinant gal3 was associated with reduced mortality and reduced fungal burden in the kidney, spleen, and lung at 24 h following infection. CONCLUSION: These findings suggest that gal3 has an active role in host defense against candidiasis and that neonatal animals can benefit from supplementation with this lectin in the setting of disseminated candidiasis.

Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review.

BACKGROUND: Reproductive function in women with end stage renal disease generally improves after kidney transplant. However, pregnancy remains challenging due to the risk of adverse clinical outcomes. METHODS: We searched PubMed/MEDLINE, Elsevier EMBASE, Scopus, BIOSIS Previews, ISI Science Citation Index Expanded, and the Cochrane Central Register of Controlled Trials from date of inception through August 2017 for studies reporting pregnancy with kidney transplant. RESULTS: Of 1343 unique studies, 87 met inclusion criteria, representing 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years. The live-birth rate was 72.9% (95% CI, 70.0-75.6). The rate of other pregnancy outcomes was as follows: induced abortions (12.4%; 95% CI, 10.4-14.7), miscarriages (15.4%; 95% CI, 13.8-17.2), stillbirths (5.1%; 95% CI, 4.0-6.5), ectopic pregnancies (2.4%; 95% CI, 1.5-3.7), preeclampsia (21.5%; 95% CI, 18.5-24.9), gestational diabetes (5.7%; 95% CI, 3.7-8.9), pregnancy induced hypertension (24.1%; 95% CI, 18.1-31.5), cesarean section (62.6, 95% CI 57.6-67.3), and preterm delivery was 43.1% (95% CI, 38.7-47.6). Mean gestational age was 34.9 weeks, and mean birth weight was 2470 g. The 2-3-year interval following kidney transplant had higher neonatal mortality, and lower rates of live births as compared to > 3 year, and < 2-year interval. The rate of spontaneous abortion was higher in women with mean maternal age < 25 years and > 35 years as compared to women aged 25-34 years. CONCLUSION: Although the outcome of live births is favorable, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making.

Overview of Pregnancy in Renal Transplant Patients.

Kidney transplantation offers best hope to women with end-stage renal disease who wish to become pregnant. Pregnancy in a kidney transplant recipient continues to remain challenging due to side effects of immunosuppressive medication, risk of deterioration of allograft function, risk of adverse maternal complications of preeclampsia and hypertension, and risk of adverse fetal outcomes of premature birth, low birth weight, and small for gestational age infants. The factors associated with poor pregnancy outcomes include presence of hypertension, serum creatinine greater than 1.4 mg/dL, and proteinuria. The recommended maintenance immunosuppression in pregnant women is calcineurin inhibitors (tacrolimus/cyclosporine), azathioprine, and low dose prednisone; and it is considered safe. Sirolimus and mycophenolate mofetil should be stopped 6 weeks prior to conception. The optimal time to conception continues to remain an area of contention. It is important that counseling for childbearing should start as early as prior to getting a kidney transplant and should be done at every clinic visit after transplant. Breast-feeding is not contraindicated and should not be discouraged. This review will help the physicians in medical optimization and counseling of renal transplant recipients of childbearing age.

Effect of dehusking and cooking on protein and dietary fibre of different genotypes of desi, kabuli and green type chickpeas (Cicer arietinum).

Dehusking and cooking are essential and important component of processing of chickpea to enhance the digestibility of essential nutrients of grains. Protein and dietary fibres are important due to their role in lowering plasma cholesterol and other health advantages. Changes during dehusking and dehusking followed by cooking on soluble protein, cellulose, hemicellulose, lignin and pectin contents of four genotypes of desi type (BG 256, JG 74, KWR 108 and DCP 92-3), four genotypes of kabuli type (BG 1053, KAK 2, JKG 1 and L 550) and two genotypes of green type (Sadabahar and BDG 112) of chickpeas (Cicer arietinum) were studied. The cellulose, hemicellulose and lignin of grain decreased to an extent of 21.6 %, 29.6 % and 27.3 % respectively on dehusking, whereas pectin recorded an increase of 26.2 % on dehusking. The cooking of dehusked grain registered a marginal increase in cellulose, lignin and pectin, but a decrease in hemicellulose content. The soluble protein recorded an increase of 21.3 % on dehusking and 26.6 % increase on cooking, as compared to unprocessed grain.