Background It has been well known that mothers with chronic kidney disease (CKD), particularly end stage renal failure (ESRF), have high rates of infertility and pregnancy-related complications such as pre-eclampsia, miscarriages, early preterm deliveries and small for gestational age (SGA) infants. Advances in multidisciplinary management including medical treatment and obstetric management of mothers with CKD in the past decade have greatly improved pregnancy outcomes. There is currently no recent data on outcomes of infants born to mothers with renal impairment in Singapore.
Objectives To stratify pregnancy outcomes of mothers with chronic kidney disease (CKD) by staging so as to improve neonatal counselling and prognostication.
Methods A single centre retrospective cohort study was conducted from August 2012 to December 2020 in a tertiary care centre in Singapore. The pregnancy outcomes of mothers with all CKD stages were included. Comparison was made between severe renal impairment (SRI) pregnancies with CKD stage 4 to 5 or requiring renal replacement therapy (RRT) versus those with mild to moderate renal impairment (MRI) in CKD stages 1 to 3 and not on RRT. Primary outcome was combined mortality or major morbidity including one or more of IVH, NEC, BPD and ROP. Secondary outcomes of interest were prematurity, small for gestational age (SGA), presence of non-reassuring fetal signs (NRFS) prior to delivery, requirement of extensive resuscitation, delivery via lower-segment cesarean section, whether the mothers had co-existing hypertension and use of anti-hypertensive during pregnancy. Discrete variables were analyzed using the chi square. Continuous variables were analyzed using Mann-Whitney U test. P < 0.05 was considered significant.
Results 74 pregnancies were included, of which 15 (20.2%) were SRI pregnancies. Compared to MRI pregnancies, SRI pregnancies had significantly higher peak urea (median ± interquartile range: 18 ± 7.8 versus 5.9 ± 4.9 mmol/L) and creatinine levels (514 ± 334 versus 70 ± 60 mmol/L), infants had lower birthweight (1170 ± 1185 grams versus 2475 ± 1105 grams) and gestational age (31 ± 7 versus 36 ± 4). Pregnancy with SRI was associated with more combined mortality or major morbidity (OR 5.889; 95% CI 1.551–22.357), prematurity (OR 10.500; 95% CI 1.278–86.276), hypertension (OR 3.352, 95% CI 1.039–10.817) and use of anti-hypertensive in pregnancy (OR 3.673, 95% CI 1.131–11.936) as well as presence of NRFS (OR 7.125, 95% CI 1.072–47.371). Sub-analyses done also showed greater odds of combined mortality and major morbidity if the CKD mothers
Conclusions Neonates of SRI pregnancies have significantly increased risk of combined mortality and morbidity, preterm birth, and foetal distress. Renal pregnancies with coexisting hypertension and especially those requiring anti-hypertensive medications had higher risks of combined mortality and morbidity. The importance of controlling hypertension and use of anti-hypertensives in CKD pregnancies are important for women with CKD who are attempting to conceive or who are already pregnant.
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