Characteristics and Outcomes of Patients With Pregnancy-Related End-Stage Kidney Disease

Overview

Journal JAMA Netw Open

Publisher American Medical Association

Specialty General Medicine

Date 2023 Dec 8

PMID 38064217

Authors

Lauren M Kucirka

Ana M Angarita

Tracy A Manuck

Kim A Boggess

Vimal K Derebail

Mollie E Wood

Michelle L Meyer

Dorry L Segev

Monica L Reynolds

Affiliations

Soon will be listed here.

Abstract

Importance: The incidence of pregnancy-related acute kidney injury is increasing and is associated with significant maternal morbidity including progression to end-stage kidney disease (ESKD). Little is known about characteristics and long-term outcomes of patients who develop pregnancy-related ESKD.

Objectives: To examine the characteristics and clinical outcomes of patients with pregnancy-related ESKD and to investigate associations between pre-ESKD nephrology care and outcomes.

Design, Setting, And Participants: This was a cohort study of 183 640 reproductive-aged women with incident ESKD between January 1, 2000, and November 20, 2020, from the US Renal Data System and maternal data from births captured in the US Centers for Disease Control and Prevention publicly available natality data. Data were analyzed from December 2022 to June 2023.

Exposure: Pregnancy-related primary cause of ESKD, per International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes reported at ESKD onset by the primary nephrologist on Centers for Medicare and Medicaid Services form 2728.

Main Outcomes Measures: Multivariable Cox proportional hazards and competing risk models were constructed to examine time to (1) mortality, (2) access to kidney transplant (joining the waiting list or receiving a live donor transplant), and (3) receipt of transplant after joining the waitlist.

Results: A total of 341 patients with a pregnancy-related primary cause of ESKD were identified (mean [SD] age 30.2 [7.3]). Compared with the general US birthing population, Black patients were overrepresented among those with pregnancy-related ESKD (109 patients [31.9%] vs 585 268 patients [16.2%]). In adjusted analyses, patients with pregnancy-related ESKD had similar or lower hazards of mortality compared with those with glomerulonephritis or cystic kidney disease (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.76-1.19), diabetes or hypertension (aHR, 0.49; 95% CI, 0.39-0.61), or other or unknown primary causes of ESKD (aHR, 0.60; 95% CI, 0.48-0.75). Despite this, patients with pregnancy-related ESKD had significantly lower access to kidney transplant compared with those with other causes of ESKD, including (1) glomerulonephritis or cystic kidney disease (adjusted subhazard ratio [aSHR], 0.51; 95% CI, 0.43-0.66), (2) diabetes or hypertension (aSHR, 0.81; 95% CI, 0.67-0.98), and (3) other or unkown cause (aSHR, 0.82; 95% CI, 0.67-0.99). Those with pregnancy-related ESKD were less likely to have nephrology care or have a graft or arteriovenous fistula placed before ESKD onset (nephrology care: adjusted relative risk [aRR], 0.47; 95% CI, 0.40-0.56; graft or arteriovenous fistula placed: aRR, 0.31; 95% CI, 0.17-0.57).

Conclusion And Relevance: In this study, those with pregnancy-related ESKD had reduced access to transplant and nephrology care, which could exacerbate existing disparities in a disproportionately Black population. Increased access to care could improve quality of life and health outcomes among these young adults with high potential for long-term survival.

References

Metcalfe A, Wick J, Ronksley P . Racial disparities in comorbidity and severe maternal morbidity/mortality in the United States: an analysis of temporal trends. Acta Obstet Gynecol Scand. 2017; 97(1):89-96. DOI: 10.1111/aogs.13245. View

Keith D, Vranic G . Approach to the Highly Sensitized Kidney Transplant Candidate. Clin J Am Soc Nephrol. 2016; 11(4):684-93. PMC: 4822662. DOI: 10.2215/CJN.05930615. View

Gillespie B, Morgenstern H, Hedgeman E, Tilea A, Scholz N, Shearon T . Nephrology care prior to end-stage renal disease and outcomes among new ESRD patients in the USA. Clin Kidney J. 2015; 8(6):772-80. PMC: 4655805. DOI: 10.1093/ckj/sfv103. View

Redd S, Rice W, Aswani M, Blake S, Julian Z, Sen B . Racial/ethnic and educational inequities in restrictive abortion policy variation and adverse birth outcomes in the United States. BMC Health Serv Res. 2021; 21(1):1139. PMC: 8532280. DOI: 10.1186/s12913-021-07165-x. View

Ely D, Driscoll A . Infant Mortality in the United States, 2020: Data From the Period Linked Birth/Infant Death File. Natl Vital Stat Rep. 2022; 71(5):1-18. View

Wesselman H, Ford C, Leyva Y, Li X, Chang C, Dew M . Social Determinants of Health and Race Disparities in Kidney Transplant. Clin J Am Soc Nephrol. 2021; 16(2):262-274. PMC: 7863655. DOI: 10.2215/CJN.04860420. View

Admon L, Winkelman T, Zivin K, Terplan M, Mhyre J, Dalton V . Racial and Ethnic Disparities in the Incidence of Severe Maternal Morbidity in the United States, 2012-2015. Obstet Gynecol. 2018; 132(5):1158-1166. DOI: 10.1097/AOG.0000000000002937. View

Layton J, Hogan S, Jennette C, Kenderes B, Krisher J, Jennette J . Discrepancy between Medical Evidence Form 2728 and renal biopsy for glomerular diseases. Clin J Am Soc Nephrol. 2010; 5(11):2046-52. PMC: 3001765. DOI: 10.2215/CJN.03550410. View

Hassan I, Junejo A, Dawani M . Etiology and outcome of acute renal failure in pregnancy. J Coll Physicians Surg Pak. 2009; 19(11):714-7. DOI: 11.2009/JCPSP.714717. View

10.

Oliverio A, Reynolds M . Overturning Roe Will Do Harm to Our Patients. Am J Kidney Dis. 2022; 80(6):697-700. DOI: 10.1053/j.ajkd.2022.08.006. View

11.

Appel L, Wright Jr J, Greene T, Agodoa L, Astor B, Bakris G . Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med. 2010; 363(10):918-29. PMC: 3662974. DOI: 10.1056/NEJMoa0910975. View

12.

Smart N, Titus T . Outcomes of early versus late nephrology referral in chronic kidney disease: a systematic review. Am J Med. 2011; 124(11):1073-80.e2. DOI: 10.1016/j.amjmed.2011.04.026. View

13.

Prakash J, Tripathi K, Malhotra V, Kumar O, Srivastava P . Acute renal failure in eastern India. Nephrol Dial Transplant. 1995; 10(11):2009-12. View

14.

Anachebe N . Racial and ethnic disparities in infant and maternal mortality. Ethn Dis. 2006; 16(2 Suppl 3):S3-71-6. View

15.

Rao S, Jim B . Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century. Kidney Int Rep. 2018; 3(2):247-257. PMC: 5932309. DOI: 10.1016/j.ekir.2018.01.011. View

16.

Laster M, Soohoo M, Hall C, Streja E, Rhee C, Ravel V . Racial-ethnic disparities in mortality and kidney transplant outcomes among pediatric dialysis patients. Pediatr Nephrol. 2016; 32(4):685-695. PMC: 5392236. DOI: 10.1007/s00467-016-3530-2. View

17.

von Elm E, Altman D, Egger M, Pocock S, Gotzsche P, Vandenbroucke J . Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007; 335(7624):806-8. PMC: 2034723. DOI: 10.1136/bmj.39335.541782.AD. View

18.

Tanne J . US lags other rich nations in maternal health care. BMJ. 2020; 371:m4546. DOI: 10.1136/bmj.m4546. View

19.

Morgan J, Foster B, Vinson A, Wong G, Lentine K, West L . Navigating the Dobbs versus Jackson America for Patients with CKD and Kidney Transplants. J Am Soc Nephrol. 2023; 34(2):201-204. PMC: 10103085. DOI: 10.1681/ASN.0000000000000049. View

20.

Tucker B, Freedman B . Need to Reclassify Etiologies of ESRD on the CMS 2728 Medical Evidence Report. Clin J Am Soc Nephrol. 2017; 13(3):477-479. PMC: 5967672. DOI: 10.2215/CJN.08310817. View