Complex Management of Nephrotic Syndrome and Kidney Failure During Pregnancy in a Type 1 Diabetes Patient: A Challenging Case

Overview

Journal J Clin Med

Specialty General Medicine

Date 2022 Oct 14

PMID 36233591

Authors

Leo Drapeau

Mathilde Beaumier

Julie Esbelin

Francois Comoz

Lucile Figueres

Giorgina Barbara Piccoli

Delphine Kervella

Affiliations

Soon will be listed here.

Abstract

Pregnancy with chronic kidney disease is challenging, and patients with diabetic nephropathy are at particular risk of a rapid kidney function decline during pregnancy. While indications for the management of pregnant patients with initial diabetic nephropathy are widely available in the literature, data on patients with severe nephrotic syndrome and kidney function impairment are lacking, and the decision on whether and when dialysis should be initiated is not univocal. We report a type 1 diabetes patient who started pregnancy with a severe nephrotic syndrome and shifted from CKD stage 3b to stage 5 during pregnancy. The management was complicated by a fetal heart malformation and by poorly controlled diabetes. The evidence for and against starting dialysis was carefully evaluated, and the choice of strict nephrological and obstetrical monitoring, nutritional management, and diuretic treatment made it possible to avoid dialysis in pregnancy, after ruling out pre-eclampsia. This experience enables examination of some open issues and contributes to the discussion of when to start dialysis in pregnancy.

References

Wiles K, Chappell L, Clark K, Elman L, Hall M, Lightstone L . Clinical practice guideline on pregnancy and renal disease. BMC Nephrol. 2019; 20(1):401. PMC: 6822421. DOI: 10.1186/s12882-019-1560-2. View

Attini R, Leone F, Parisi S, Fassio F, Capizzi I, Loi V . Vegan-vegetarian low-protein supplemented diets in pregnant CKD patients: fifteen years of experience. BMC Nephrol. 2016; 17(1):132. PMC: 5029029. DOI: 10.1186/s12882-016-0339-y. View

Bramham K, Seed P, Lightstone L, Nelson-Piercy C, Gill C, Webster P . Diagnostic and predictive biomarkers for pre-eclampsia in patients with established hypertension and chronic kidney disease. Kidney Int. 2016; 89(4):874-85. DOI: 10.1016/j.kint.2015.10.012. View

Spotti D . Pregnancy in women with diabetic nephropathy. J Nephrol. 2018; 32(3):379-388. DOI: 10.1007/s40620-018-0553-8. View

Persson M, Norman M, Hanson U . Obstetric and perinatal outcomes in type 1 diabetic pregnancies: A large, population-based study. Diabetes Care. 2009; 32(11):2005-9. PMC: 2768194. DOI: 10.2337/dc09-0656. View

Oyen N, Diaz L, Leirgul E, Boyd H, Priest J, Mathiesen E . Prepregnancy Diabetes and Offspring Risk of Congenital Heart Disease: A Nationwide Cohort Study. Circulation. 2016; 133(23):2243-53. PMC: 4890838. DOI: 10.1161/CIRCULATIONAHA.115.017465. View

Orozco-Guillien A, Munoz-Manrique C, Reyes-Lopez M, Perichat-Perera O, Miranda-Araujo O, DAlessandro C . Quality or Quantity of Proteins in the Diet for CKD Patients: Does "Junk Food" Make a Difference? Lessons from a High-Risk Pregnancy. Kidney Blood Press Res. 2021; 46(1):1-10. DOI: 10.1159/000511539. View

Jesudason S, Grace B, McDonald S . Pregnancy outcomes according to dialysis commencing before or after conception in women with ESRD. Clin J Am Soc Nephrol. 2013; 9(1):143-9. PMC: 3878697. DOI: 10.2215/CJN.03560413. View

Bramham K . Diabetic Nephropathy and Pregnancy. Semin Nephrol. 2017; 37(4):362-369. DOI: 10.1016/j.semnephrol.2017.05.008. View

10.

Attini R, Montersino B, Leone F, Minelli F, Fassio F, Rossetti M . Dialysis or a Plant-Based Diet in Advanced CKD in Pregnancy? A Case Report and Critical Appraisal of the Literature. J Clin Med. 2019; 8(1). PMC: 6352283. DOI: 10.3390/jcm8010123. View

11.

Rivera J, Perez Lopez M, Corzo Bermudez C, Covarrubias L, Bermudez Aceves L, Chucuan Castillo C . Delayed Initiation of Hemodialysis in Pregnant Women with Chronic Kidney Disease: Logistical Problems Impact Clinical Outcomes. An Experience from an Emerging Country. J Clin Med. 2019; 8(4). PMC: 6518183. DOI: 10.3390/jcm8040475. View

12.

Fleiss B, Wong F, Brownfoot F, Shearer I, Baud O, Walker D . Knowledge Gaps and Emerging Research Areas in Intrauterine Growth Restriction-Associated Brain Injury. Front Endocrinol (Lausanne). 2019; 10:188. PMC: 6449431. DOI: 10.3389/fendo.2019.00188. View

13.

Asamiya Y, Otsubo S, Matsuda Y, Kimata N, Kikuchi K, Miwa N . The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int. 2009; 75(11):1217-1222. DOI: 10.1038/ki.2009.48. View

14.

Murphy H, Howgate C, OKeefe J, Myers J, Morgan M, Coleman M . Characteristics and outcomes of pregnant women with type 1 or type 2 diabetes: a 5-year national population-based cohort study. Lancet Diabetes Endocrinol. 2021; 9(3):153-164. DOI: 10.1016/S2213-8587(20)30406-X. View

15.

Rossing K, Jacobsen P, Hommel E, Mathiesen E, Svenningsen A, Rossing P . Pregnancy and progression of diabetic nephropathy. Diabetologia. 2002; 45(1):36-41. DOI: 10.1007/s125-002-8242-4. View

16.

Macintosh M, Fleming K, Bailey J, Doyle P, Modder J, Acolet D . Perinatal mortality and congenital anomalies in babies of women with type 1 or type 2 diabetes in England, Wales, and Northern Ireland: population based study. BMJ. 2006; 333(7560):177. PMC: 1513435. DOI: 10.1136/bmj.38856.692986.AE. View

17.

Jesudason S, Hewawasam E, Moloney B, Tan R, Li J, Blakey H . Comparison of catheters or new arteriovenous fistulas for commencement of haemodialysis in pregnant women with chronic kidney disease: an international observational study. J Nephrol. 2022; 35(6):1689-1698. PMC: 9300570. DOI: 10.1007/s40620-022-01288-y. View

18.

Mathiesen E, Ali N, Alibegovic A, Anastasiou E, Cypryk K, de Valk H . Risk of Major Congenital Malformations or Perinatal or Neonatal Death With Insulin Detemir Versus Other Basal Insulins in Pregnant Women With Preexisting Diabetes: The Real-World EVOLVE Study. Diabetes Care. 2021; 44(9):2069-2077. PMC: 8740922. DOI: 10.2337/dc21-0472. View

19.

Karge A, Beckert L, Moog P, Haller B, Ortiz J, Lobmaier S . Role of sFlt-1/PIGF ratio and uterine Doppler in pregnancies with chronic kidney disease suspected with Pre-eclampsia or HELLP syndrome. Pregnancy Hypertens. 2020; 22:160-166. DOI: 10.1016/j.preghy.2020.09.007. View

20.

Piccoli G, Tavassoli E, Melluzza C, Grassi G, Monzeglio C, Donvito V . Severe diabetic nephropathy in type 1 diabetes and pregnancy--a case series. Rev Diabet Stud. 2013; 10(1):68-78. PMC: 3932073. DOI: 10.1900/RDS.2013.10.68. View