Abstract
The number of pregnancies in women with pregestational diabetes has been steadily increasing worldwide. These pregnancies are associated with an increased risk of a variety of complications, including miscarriages, congenital malformations, macrosomia, fetal growth restriction, preeclampsia, preterm delivery and stillbirth. In pregnant women with diabetic nephropathy it is important to evaluate both the effect of pregnancy on kidney function and the effect of kidney disease on pregnancy outcomes. Pregnant women with normal renal function and microalbuminuria have a low risk of loss of kidney function during pregnancy, while women with GFR < 60 ml/min and/or proteinuria ≥ 3 g/24 h at the beginning of pregnancy are at risk of permanent kidney damage. The risk of fetal and maternal complications is associated with the severity of chronic kidney disease and glycemic control. Advances in prenatal care have improved fetal and maternal outcomes and preconception counseling has become key for a successful pregnancy in all women with diabetes and especially in those with diabetes and chronic kidney disease.
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References
Lawrence JM, Contreras R, Chen W, Sacks DA (2008) Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, 1999–2005. Diabetes Care 31:899–904. https://doi.org/10.2337/dc07-2345
Writing Group for the SEARCH for Diabetes in Youth Study Group, Dabelea D, Bell RA et al (2007) Incidence of diabetes in youth in the United States. JAMA 297:2716–2724. https://doi.org/10.1001/jama.297.24.2716
Temple R, Murphy H (2010) Type 2 diabetes in pregnancy—an increasing problem. Best Pract Res Clin Endocrinol Metab 24:591–603. https://doi.org/10.1016/j.beem.2010.05.011
WHO Regional Office for Europe and the International Diabetes Federation (IDF), European Region (1990) Diabetes care and research in Europe: the Saint Vincent declaration. Diabet Med 7:360
Kitzmiller JL, Wallerstein R, Correa A, Kwan S (2010) Preconception care for women with diabetes and prevention of major congenital malformations. Birth Defects Res Part A Clin Mol Teratol 88:791–803. https://doi.org/10.1002/bdra.20734
Persson M, Norman M, Hanson U (2009) Obstetric and perinatal outcomes in type 1 diabetic pregnancies: a large, population-based study. Diabetes Care 32:2005–2009. https://doi.org/10.2337/dc09-0656
Carr DB, Koontz GL, Gardella C et al (2006) Diabetic nephropathy in pregnancy: suboptimal hypertensive control associated with preterm delivery. Am J Hypertens 19:513–519. https://doi.org/10.1016/j.amjhyper.2005.12.010
Ekbom P, Damm P, Feldt-Rasmussen B et al (2001) Pregnancy outcome in type 1 diabetic women with microalbuminuria. Diabetes Care 24:1739–1744
Nielsen LR, Damm P, Mathiesen ER (2009) Improved pregnancy outcome in type 1 diabetic women with microalbuminuria or diabetic nephropathy: effect of intensified antihypertensive therapy? Diabetes Care 32:38–44. https://doi.org/10.2337/dc08-1526
Kitzmiller JL, Montoro MN (2008) Diabetic nephropathic and pregnancy. In: Kitzmiller JL, Jovanovic L, Brown F, Coustan D, Reader DM (eds) Managing preexisting diabetes and pregnancy. American Diabetes Association, Arlington, pp 374–386
Gordon M, Landon MB, Samuels P et al (1996) Perinatal outcome and long-term follow-up associated with modern management of diabetic nephropathy. Obstet Gynecol 87:401–409
Dunne FP, Chowdhury TA, Hartland A et al (1999) Pregnancy outcome in women with insulin-dependent diabetes mellitus complicated by nephropathy. QJM 92:451–454
Biesenbach G, Stöger H, Zazgornik J (1992) Influence of pregnancy on progression of diabetic nephropathy and subsequent requirement of renal replacement therapy in female type I diabetic patients with impaired renal function. Nephrol Dial Transplant 7:105–109
Kimmerle R, Zass RP, Cupisti S et al (1995) Pregnancies in women with diabetic nephropathy: long-term outcome for mother and child. Diabetologia 38:227–235
Purdy LP, Hantsch CE, Molitch ME et al (1996) Effect of pregnancy on renal function in patients with moderate-to-severe diabetic renal insufficiency. Diabetes Care 19:1067–1074
Kitzmiller JL, Brown ER, Phillippe M et al (1981) Diabetic nephropathy and perinatal outcome. Am J Obstet Gynecol 141:741–751
Reece EA, Winn HN, Hayslett JP et al (1990) Does pregnancy alter the rate of progression of diabetic nephropathy? Am J Perinatol 7:193–197. https://doi.org/10.1055/s-2007-999479
Dicker D, Feldberg D, Peleg D et al (1986) Pregnancy complicated by diabetic nephropathy. J Perinat Med 14:299–307
Grenfell A, Brudenell JM, Doddridge MC, Watkins PJ (1986) Pregnancy in diabetic women who have proteinuria. Q J Med 59:379–386
Reece EA, Coustan DR, Hayslett JP et al (1988) Diabetic nephropathy: pregnancy performance and fetomaternal outcome. Am J Obstet Gynecol 159:56–66
Mackie AD, Doddridge MC, Gamsu HR et al (1996) Outcome of pregnancy in patients with insulin-dependent diabetes mellitus and nephropathy with moderate renal impairment. Diabet Med 13:90–96. https://doi.org/10.1002/(SICI)1096-9136(199601)13:1<90::AID-DIA992>3.0.CO;2-M
Reece EA, Leguizamon G, Homko C (1998) Pregnancy performance and outcomes associated with diabetic nephropathy. Am J Perinatol 15:413–421. https://doi.org/10.1055/s-2007-993968
Miodovnik M, Rosenn BM, Khoury JC et al (1996) Does pregnancy increase the risk for development and progression of diabetic nephropathy? Am J Obstet Gynecol 174:1180–1189 (discussion 1189–91)
Reece EA, Leguizamon G, Homko C (1998) Stringent controls in diabetic nephropathy associated with optimization of pregnancy outcomes. J Matern Fetal Med 7:213–216. https://doi.org/10.1002/(SICI)1520-6661(199807/08)7:4%3C213::AID-MFM11%3E3.0.CO;2-E
Brenner BM, Cooper ME, de Zeeuw D et al (2001) Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. NEJM 345:861–869. https://doi.org/10.1056/NEJMoa011161
Lewis EJ, Hunsicker LG, Clarke WR et al (2001) Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. NEJM 345:851–860. https://doi.org/10.1056/NEJMoa011303
Irfan S, Arain TM, Shaukat A, Shahid A (2004) Effect of pregnancy on diabetic nephropathy and retinopathy. J Coll Physicians Surg Pak 14:75–78
Rossing K, Jacobsen P, Hommel E et al (2002) Pregnancy and progression of diabetic nephropathy. Diabetologia 45:36–41. https://doi.org/10.1007/s001250200003
Sandvik MK, Iversen BM, Irgens LM et al (2010) Are adverse pregnancy outcomes risk factors for development of end-stage renal disease in women with diabetes? Nephrol Dial Transplant 25:3600–3607. https://doi.org/10.1093/ndt/gfq275
Mathiesen ER, Ringholm L, Feldt-Rasmussen B et al (2012) Obstetric nephrology: pregnancy in women with diabetic nephropathy—the role of antihypertensive treatment. Clin J Am Soc Nephrol 7:2081–2088. https://doi.org/10.2215/CJN.00920112
Piccoli GB, Tavassoli E, Melluzza C et al (2013) Severe diabetic nephropathy in type 1 diabetes and pregnancy—a case series. Rev Diabet Stud 10:68–78. https://doi.org/10.1900/RDS.2013.10.68
Hod M, van Dijk DJ, Karp M et al (1995) Diabetic nephropathy and pregnancy: the effect of ACE inhibitors prior to pregnancy on fetomaternal outcome. Nephrol Dial Transplant 10:2328–2333
Damm JA, Asbjörnsdóttir B, Callesen NF et al (2013) Diabetic nephropathy and microalbuminuria in pregnant women with type 1 and type 2 diabetes: prevalence, antihypertensive strategy, and pregnancy outcome. Diabetes Care 36:3489–3494. https://doi.org/10.2337/dc13-1031
Vérier-Mine O, Chaturvedi N, Webb D, Fuller JH (2005) Is pregnancy a risk factor for microvascular complications? The EURODIAB prospective complications study. Diabet Med 22:1503–1509. https://doi.org/10.1111/j.1464-5491.2005.01682.x
American Diabetes Association (2004) Preconception care of women with diabetes. Diabetes Care 27(Suppl 1):S76–S78
Young EC, Pires MLE, Marques LPJ et al (2011) Effects of pregnancy on the onset and progression of diabetic nephropathy and of diabetic nephropathy on pregnancy outcomes. Diabetes Metab Syndr 5:137–142. https://doi.org/10.1016/j.dsx.2012.02.013
Nielsen LR, Müller C, Damm P, Mathiesen ER (2006) Reduced prevalence of early preterm delivery in women with type 1 diabetes and microalbuminuria—possible effect of early antihypertensive treatment during pregnancy. Diabet Med 23:426–431. https://doi.org/10.1111/j.1464-5491.2006.01831.x
Rosenn BM, Miodovnik J, Khoury H et al (1997) Outcome of pregnancy in women with diabetic nephropathy. Am J Obstet Gynecol 176:S179
Bramham K (2017) Diabetic nephropathy and pregnancy. Semin Nephrol 37:362–369. https://doi.org/10.1016/j.semnephrol.2017.05.008
Ballas J, Moore TR, Ramos GA (2012) Management of diabetes in pregnancy. Curr Diabetes Rep 12:33–42. https://doi.org/10.1007/s11892-011-0249-0
Sibai BM, Caritis S, Hauth J et al (2000) Risks of preeclampsia and adverse neonatal outcomes among women with pregestational diabetes mellitus. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Am J Obstet Gynecol 182:364–369
Sibai BM (2000) Risk factors, pregnancy complications, and prevention of hypertensive disorders in women with pregravid diabetes mellitus. J Matern Fetal Med 9:62–65
Klemetti MM, Laivuori H, Tikkanen M et al (2015) Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988–2011. Diabetologia 58:678–686. https://doi.org/10.1007/s00125-014-3488-1
Leach L, Taylor A, Sciota F (2009) Vascular dysfunction in the diabetic placenta: causes and consequences. J Anat 215:69–76. https://doi.org/10.1111/j.1469-7580.2009.01098.x
Combs CA, Rosenn B, Kitzmiller JL et al (1993) Early-pregnancy proteinuria in diabetes related to preeclampsia. Obstet Gynecol 82:802–807
How HY, Sibai B, Lindheimer M et al (2004) Is early-pregnancy proteinuria associated with an increased rate of preeclampsia in women with pregestational diabetes mellitus? Am J Obstet Gynecol 190:775–778. https://doi.org/10.1016/j.ajog.2003.11.031
Yogev Y, Chen R, Ben-Haroush A et al (2010) Maternal overweight and pregnancy outcome in women with type-1 diabetes mellitus and different degrees of nephropathy. J Matern Fetal Neonatal Med 23:999–1003. https://doi.org/10.3109/14767050903544744
Clausen TD, Mathiesen E, Ekbom P et al (2005) Poor pregnancy outcome in women with type 2 diabetes. Diabetes Care 28:323–328
Boulot P, Chabbert-Buffet N, d’Ercole C et al (2003) French multicentric survey of outcome of pregnancy in women with pregestational diabetes. Diabetes Care 26:2990–2993
Lapolla A, Dalfrà MG, Di Cianni G et al (2008) A multicenter Italian study on pregnancy outcome in women with diabetes. Nutr Metab Cardiovasc Dis 18:291–297. https://doi.org/10.1016/j.numecd.2006.12.001
Dunne F, Brydon P, Smith K, Gee H (2003) Pregnancy in women with type 2 diabetes: 12 years outcome data 1990–2002. Diabet Med 20:734–738
Lapolla A, Dalfrà MG, Fedele D (2008) Pregnancy complicated by type 2 diabetes: an emerging problem. Diabetes Res Clin Pract 80:2–7. https://doi.org/10.1016/j.diabres.2007.11.009
Hillman N, Herranz L, Vaquero PM et al (2006) Is pregnancy outcome worse in type 2 than in type 1 diabetic women? Diabetes Care 29:2557–2558. https://doi.org/10.2337/dc06-0680
Macintosh MCM, Fleming KM, Bailey JA et al (2006) 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 333:177. https://doi.org/10.1136/bmj.38856.692986.AE
Roland JM, Murphy HR, Ball V et al (2005) The pregnancies of women with type 2 diabetes: poor outcomes but opportunities for improvement. Diabet Med 22:1774–1777. https://doi.org/10.1111/j.1464-5491.2005.01784.x
Temple R (2011) Preconception care for women with diabetes: is it effective and who should provide it? Best Pract Res Clin Obstet Gynaecol 25:3–14. https://doi.org/10.1016/j.bpobgyn.2010.10.001
Biesenbach G, Zazgornik J, Stöger H et al (1994) Abnormal increases in urinary albumin excretion during pregnancy in IDDM women with pre-existing microalbuminuria. Diabetologia 37:905–910
Li D-K, Yang C, Andrade S et al (2011) Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study. BMJ 343:d5931–d5931. https://doi.org/10.1136/bmj.d5931
The American Diabetes Association (ADA) (2018) Management of diabetes in pregnancy. Stand Med Care Diabetes Care 41:S137–S143
Società Italiana di Diabetologia (SID) and Associazione Medici Diabetologi (AMD) (2014) Standard italiani per la cura del diabete mellito. https://www.standarditaliani.it
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Spotti, D. Pregnancy in women with diabetic nephropathy. J Nephrol 32, 379–388 (2019). https://doi.org/10.1007/s40620-018-0553-8
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DOI: https://doi.org/10.1007/s40620-018-0553-8