Pregnancy outcomes in women with chronic kidney disease: a systematic review

Summary

Background and objectives

Pregnant women with chronic kidney disease (CKD) are at risk of adverse maternal and fetal outcomes. We conducted a systematic review of observational studies that described this risk.

Design, setting, participants, & measurements

We searched several databases from their date of inception through June 2010 for eligible articles published in any language. We included any study that reported maternal or fetal outcomes in at least five pregnant women in each group with or without CKD. We excluded pregnant women with a history of transplantation or maintenance dialysis.

Results

We identified 13 studies. Adverse maternal events including gestational hypertension, pre-eclampsia, eclampsia, and maternal mortality were reported in 12 studies. There were 312 adverse maternal events among 2682 pregnancies in women with CKD (weighted average of 11.5%) compared with 500 events in 26,149 pregnancies in normal healthy women (weighted average of 2%). One or more adverse fetal outcomes such as premature births, intrauterine growth restriction, small for gestational age, neonatal mortality, stillbirths, and low birth weight were reported in nine of the included studies. Overall, the risk of developing an adverse fetal outcome was at least two times higher among women with CKD compared with those without.

Conclusions

This review summarizes current available evidence to guide physicians in their decision-making, advice, and care for pregnant women with CKD. Additional studies are needed to better characterize the risks.     

Pregnancy outcomes in women with ankylosing spondylitis: a scoping literature and methodological review

Clinical Rheumatology - In this scoping review, we sought to summarize the types of outcomes collected in pregnant patients with ankylosing spondylitis (AS), and to identify some methodological...     

Being a parent on dialysis: a literature review

Aim: This literature review explored the extant literature to further our understanding of the experience of being a parent on dialysis. Methods: Keywords used to search the literature were haemodialysis, hemodialysis, chronic kidney disease, end stage renal disease, parent and experience. Databases searched included CINAHL, Medline, Wiley/Blackwell, EBSCOHost, Web of Science, Pubmed and ProQuest. Years included were 1999–2009. Seventeen primary research articles (sixteen qualitative, one mixed methods) met the search criteria with only one on parents undergoing dialysis. Findings: The experience of the parent on dialysis has rarely been explored in the literature. Related research has indicated important themes including: restricted lives; relationships; adjustment; consequences and future outlook. Conclusions: More should be known about challenges that face parents who receive dialysis. This review established an urgent need for further research to determine the experiences and needs of this population to provide empirical, person‐centred nursing care.     

Pregnancy outcomes in women with liver transplants: systematic review and meta-analysis

BackgroundDespite increasing reports of pregnancy in liver transplant recipients, questions remain about the impact of transplantation in pregnancy.MethodsThis systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 26th December 2019 for studies reporting pregnancy with liver transplant. A meta-analysis was conducted with the use of random-effects modelling and prospectively registered with the PROSPERO database.ResultsOf 1239 unique studies, 28 met inclusion criteria, representing 1496 pregnancies in 1073 liver transplant recipients. The live-birth rate was 85.6% (CI95%: 80.5%–90.7%). The rate of other pregnancy outcomes was as follows: induced abortions (5.7%), miscarriages (7.8%) and stillbirths (3.3%). Pooled rates of obstetric complications were hypertension (18.2%), pre-eclampsia (12.8%) and gestational diabetes (7.0%). Pooled rates of delivery outcomes for caesarean section (C-section) and pre-term birth were 42.2% and 27.8%, respectively.ConclusionIn conclusion, live birth outcomes are good among liver transplant recipients and this favourable trend is consistent at an international level. However, special attention should be given to obstetric complications such as hypertension, pre-eclampsia, and preterm delivery. The high incidence of these complications supports the high-risk classification of post-liver transplant pregnancies and it is necessary for a multidisciplinary team to be involved in the monitoring and counselling of liver transplant recipients both before and during pregnancy. Whilst majority data originate from institutions from high-income countries, data from low-middle income countries (LMIC) are needed owing to rising rates of liver transplantation in LMIC.     

Pregnancy and acromegaly: a review

To review the literature regarding the diagnosis and management of acromegaly during pregnancy. A systematic literature search was performed using MEDLINE including hand-searching reference lists from original articles. The diagnosis of acromegaly during pregnancy is made difficult due to the physiologic changes in pituitary GH secretion and IGF-1 production resulting from placental GH secretion and the inability of commercial assays to discriminate between pituitary and placental GH. Most patients with acromegaly during pregnancy do not have an increase in tumor size, metabolic complications are uncommon, and neonatal outcome is largely unaffected. IGF-1 levels tend to be stable in such patients possibly due to the high estrogen levels causing GH resistance. Dopamine agonists, somatostatin analogues, and a GH receptor antagonist have been reported to be safe during pregnancy. Patients with visual field defects should be considered for surgery, but in most cases this can be safely postponed until after delivery. Overall, pregnancy in acromegaly is uneventful and newborns unaffected. Dopamine agonists and somatostatin analogues have not been associated with major adverse effects to the fetus; however, more data are needed to validate their safety.     

Body fluid abnormalities in severe hyperglycemia in patients on chronic dialysis: review of published reports

Reports of dialysis-associated hyperglycemia (DH) were compared to reports of diabetic ketoacidosis (DKA) and nonketotic hyperglycemia (NKH) in patients with preserved renal function. Average serum values in DH (491 observations), DKA (1036 observations), and NKH (403 observations) were as follows, respectively: glucose, 772, 649, and 961 mg/dl; sodium, 127, 134, and 149, mmol/l; and tonicity, 298, 304, and 355 mOsm/kg. Assuming that euglycemic (serum glucose, 90 mg/dl) values were the same (sodium, 140 mmol/l; tonicity, 285 mOsm/kg) for all three states, the hyperglycemic rise in the average serum tonicity value per 100-mg/dl rise in serum glucose concentration was 1.9 mOsm/kg in DH, 3.5 mOsm/kg in DKA, and 8.1 mOsm/kg in NKH. Neurological manifestations in DH patients were caused by coexisting conditions (ketoacidosis, sepsis, and neurological disease) in most instances, and by severe hypertonicity (>320 mOsm/kg), with clearing after insulin administration, in a few instances. In 148 episodes of DH corrected with insulin only, the mean increase in serum sodium per 100-mg/dl decrease in serum glucose (Delta[Na]/Delta[Glu]) was -1.61 mmol/l. In agreement with theoretical predictions, Delta[Na]/Delta[Glu] was numerically smaller in patients with edema than in those with euvolemia. The average hyperglycemic increase in extracellular volume, calculated from changes in serum sodium concentration during correction of DH using insulin alone, was 0.013 l/l per 100-mg/dl increase in serum glucose concentration. A small number of DH patients presented with pulmonary edema rectified by insulin alone. DH causes modest hypertonicity, with few patients having neurological manifestations caused usually by other coexisting conditions. In contrast to DKA or NKH, which usually presents with hypovolemia, DH causes hypervolemia manifested occasionally by pulmonary edema. Insulin is adequate treatment for DH.     

Pituitary hormones in women with chronic renal failure: the effect of chronic intermittent haemo- and peritoneal dialysis.

Measurements of plasma prolactin (hPr), growth hormone (HGH), thyrotrophin (TSH), luteinizing (LH)--and follicle stimulating hormone (FSH) were performed in 20 women with chronic renal failure on regular dialysis. There was no significant difference in any of the hormone levels before and after the dialysis and no significant influence of the type of dialysis (haemodialysis and peritoneal dialysis) or the time of dialysis. Higher levels of plasma prolactin was found in the women on peritoneal dialysis than in the haemodialyzed women presumably due to the medical treatment. In the peritoneally dialyzed group four women had irregular menstruations and normal gonadotrophic levels, but elevated hPr and it is suggested that this finding is similar to that seen in the amenorrhoeagalactorrhoea syndrome, where hPr presumably in some way have antigonadotrophic actions at the gonadal level.     

Aspergillus peritonitis in a lupus patient on chronic peritoneal dialysis

A woman on continuous ambulatory peritoneal dialysis (CAPD) due to renal failure in systemic lupus erythematosus (SLE) developed fungal peritonitis and survived following treatment with amphotericin B and removal of the dialysis catheter. The causative organism, Aspergillus fumigatus is very rare in fungal peritonitis and may be related in this case to the combination of SLE, end-stage renal disease (ESRD) and their treatment.     

Body composition analysis in chronic dialysis patients: a longitudinal study

ObjectiveNutritional status is an important determinant of morbidity and mortality in dialysis patients. Body composition analysis bioelectrical impedance techniques are becoming commonplace in the clinical setting. Our objective is to report our clinical experience using bioelectrical impedance analysis for the prospective nutritional surveillance of dialysis patients.MethodsA total of 204 patients, 157 on hemodialysis and 47 on peritoneal dialysis were followed for a median of 21 months. Values from the first trimester were averaged and compared to those obtained in the last trimester. Bioelectrical impedance values were obtained using a single frequency (50 kHz) bioimpedance analyzer.ResultsBaseline values for body weight, height, body mass index and body surface area were similar in both treatment modalities. Hemodialysis patients lost a discreet amount of body weight (1.5%, p=0.0334). Body weight did not change in peritoneal dialysis patients. Significant decreases in resistance (p=0.l0023) and phase angle (p=0.0481) were noted in hemodialysis but not peritoneal dialysis patients. A small but significant decrease in fat free (1.8%; p=0.0028) and body cell free (3.3%; p=0.0036) mass was noted in hemodialysis but not peritoneal dialysis patients.Conclusions1. Bioelectrical impedance analysis may detect losses in fat free mass and body cell mass that are not apparent by body weight monitoring. 2. Bioelectrical impedance analysis is a practical clinical tool for evaluating body composition in dialysis patients.     

Psychological stress and strain in dialysis staff: a systematic review

Backgroung : As the number of dialysis patients increases, the psychological stress and strain suffered by dialysis personnel is of growing importance. For this reason a systematic review of the international literature was performed. Methods: A search of relevant databases for original studies or reviews published after 1990 resulted in 20 articles. The quality of these studies was assessed and they were grouped according to their focused central issues. Results: Stress and burnout were examined in 10 studies and a review. Working conditions and working situation in general were examined in eight studies. The findings were heterogeneous and difficult to compare. The results indicate that employees in the dialysis sector are subject to moderate levels of stress and burnout. Job satisfaction seems to be good. The few studies that allowed for comparison with other professions did not reveal excess stress and strain in dialysis personnel. Conclusion: The results do not indicate that dialysis workers are exposed to above‐average levels of stress or strain. Nevertheless, there is room for optimisation and need for action in some facilities.     

Trichomoniasis treatment in women: a systematic review

objective  To compare the effectiveness of various treatment strategies for trichomoniasis in women.
data sources  Medline from 1966 to1996, Embase from 1986 to 1996, Science Citation Index from 1990 to 1996; reference lists of existing reviews; through the manufacturers of metronidazole and tinidazole in the UK, the Cochrane Controlled Trials Register until October 1997 and informal discovery.
study selection  Any randomized or quasi-randomized trial in nonpregnant women with trichomoniasis where different treatment strategies were compared. 45 of the 124 identified studies met the criteria and were included in the review.
data extraction  Settings, diagnostic methods, exclusions, loss to follow-up and partner treatment strategies were extracted. Outcomes sought were parasitological cure, clinical cure and side-effects of treatment.
results  Most trials were small, with only two trials containing more than 100 women in each comparison group. Only 11 trials followed up women for more than one month. Oral nitroimidazoles were effective in achieving parasitological cure. Fourteen trials compared different treatment strategies with the remainder comparing different doses or different drugs. Partner treatment was effective in decreasing longer-term re-infection rates in the one trial testing this.
conclusions  Parasitological cure can be achieved by a single oral dose of nitroimidazoles. There is, however, very little data on partner treatment strategies and long-term cure rates after initial treatment. Further research should test various partner treatment strategies to prevent re-infections and reduce trichomoniasis prevalence.     

Costs of chronic dialysis in a public hospital: myths and realities

In this study regular dialysis treatment costs during 1998 and 1999 in a public hospital, which is responsible for a population of 178,000, has been analysed. Hemodialysis (HD) and peritoneal dialysis (PD) costs have been differentiated and compared with those of external providers. The best technical and productive efficiency of both treatments have been estimated by analyzing the "treatment cost/human resources of the community utilized" relationship. The HD treatment costs per patient per year were 20,343 and 18,871 euros in 1988 and 1,999, respectively, lower than the costs reported in other studies. In 1999 these costs were similar to those of external providers and lower than the PD treatment costs (23,295 euros). HD retains its advantage even after costs of erythropoietin, hospital admissions and transport are included. In the hospital studied, the best technical efficiency in HD would be reached with 64 patients on treatment (17,851 euros per patient per year) and in PD with 48 patients (21,167 euros per patient per year). If we take into account our population characteristics and consider a patient distribution of 70% on HD and 30% on PD, the best productive efficiency would be reached with 56 patients on HD (17,916 euros per patient per year) and 24 patients on PD (21,813 euros per patient per year). HD confers the greatest economic and social benefits on the population supplied by the hospital since it provides the community with more jobs than PD in relation to treatment costs while the two yield the same clinical results. In conclusion, HD in a public hospital, at least in our environment, may be efficient and competitive with HD from external providers and it may be more efficient and provide a bigger economic and social profit for the population serviced by the hospital than PD, at least while the current supply systems for this treatment in our country are maintained.     

Pregnancy outcomes in asthmatic women

Asthma is considered to be the most common respiratory disorder complicating pregnancy. Seventy-six asthmatic and 152 non-asthmatic pregnant women were studied. Maternal asthma was significantly associated with adverse infant outcomes, including prematurity, low birth weight and the need for Cesarean delivery. The results of this study could indicate that pregnant women with asthma were at substantially increased risk for adverse infant outcomes and suggest the need for extra attention to mothers with asthma before and during pregnancy.     

Pregnancy in women with heart defects: outlook on the problem

Modern approach to management of pregnancy and delivery in women with heart defects is presented in this paper. The 3-level system of observation of this contingent of patients is based on stratification of risk of development of cardiological complications which allows to form an algorithm of physicians actions, and to optimize tactics of ambulatory and hospital stages of treatment. Stratification of risk is supplemented with quantitative echocardiographic parameters which reflect hemodynamic overload of the myocardium and facilitate work of a practical physician. Special consideration is given to pregnant women subjected to palliative cardiac surgery. If contractile function is preserved these women have good prognosis relative to prolongation of pregnancy and unassisted delivery.     

Acute pancreatitis in peritoneal dialysis: a case report with literature review

Abdominal pain with a discoloured dialysate in a patient on peritoneal dialysis (PD) is usually attributed to infective peritonitis. Although acute pancreatitis (AP) is not usually a complication of end-stage renal disease, some studies suggest an increased risk especially in patients on PD. We report a case of idiopathic AP in a 41-year-old female on PD who presented with abdominal pain, fever, vomiting and a clear dark dialysate. Initial diagnosis of PD-associated infective peritonitis was made but dialysate cultures proved negative. Serum amylase showed a mild rise and computed tomography revealed necrotising pancreatitis. No common risk factors for AP were identified and she was successfully treated with conservative therapy. A literature review was carried out using a PubMed search with the words 'acute pancreatitis and peritoneal dialysis'. The literature search found a total of 94 cases of AP in the setting of PD. In more than a quarter, no cause for AP was found. Serum amylase was normal in 12.8% of episodes. Complications developed in 25 cases, and 28 patients died from the condition. Therefore, AP can be a rare, but serious complication of PD with a high mortality and must be considered in the differential diagnosis of abdominal pain in a PD patient.