Journal of Nephrology

, Volume 30, Issue 3, pp 303–305

Pregnancy and kidney disease: from medicine based on exceptions to exceptional medicine

Editorial
Part of the following topical collections:
  1. Obstetric Nephrology

Abstract

The Webster dictionary defines exception as an anomaly, a person or thing that does not follow a rule, while the adjective exceptional has a different nuance, and means “above average”. These two words may describe how obstetric nephrology has shifted from the description of very rare cases, to the development of a complex new and fascinating branch of medicine, that counterbalances obstetricians’ usually optimistic outlook by focusing on subtle challenges posed by chronic diseases, and mitigate the frequently grim approach of nephrologists, with a message of hope: women with kidney disease can have the same basic life goals as healthy women their age. Although studies relating to kidney disease in pregnancy are being published more frequently, not all questions have been considered or answered, and clinicians are often challenged by a lack of detailed information and practical guidelines. Thus in this complex, difficult, but also fascinating and evolving panorama, the Journal of Nephrology is publishing a issue dedicated to obstetric nephrology, in an attempt to contribute to the development of this field, with the specific aim of offering practical insights and critical contributions capable of helping clinicians in the management of these “exceptional exceptions”.

“…ninna nanna, ninna oh,

questo bimbo a chi lo do?

Lo darò al lupo nero,

Che lo tiene un anno intero

Lo darò al cavallo bianco,

Che lo culla finch’è stanco

Lo darò alla sua mamma,

Che gli canta la ninna nanna”.

Ninna nanna popolare italiana

“... Lullaby, oh lullaby,

Who should I give this child to?

I’ll give him to the black wolf,

Who will keep him for a year.

I’ll give him to the white horse,

Who will rock him till he’s tired.

I’ll give him to his mammy,

Who will sing him this lullaby.”

Traditional Italian lullaby

The Webster dictionary defines exception as an anomaly, a person or thing that does not follow a rule, while the adjective exceptional has a different nuance, and means “above average”. These two words may describe how obstetric nephrology has shifted from the description of very rare cases, to the development of a complex new and fascinating branch of medicine, that counterbalances obstetricians’ usually optimistic outlook by focusing on subtle challenges posed by chronic diseases, and mitigate the frequently grim approach of nephrologists, with a message of hope: women with kidney disease can have the same basic life goals as healthy women their age [1, 2] (Fig. 1).

Fig. 1

Jean Yves Blais: Gipsy mother. 2000 about, Sarthe, France. Jean Yves Blais is a French voyager and photographer. I asked him how he choses the subjects he photographs, and he answered: “I take pictures of people I admire”. “I admire gipsies for their pride and courage of remaining themselves in a changing world”. Thus we chose this image in honour of the courage and pride of the many women who chose to have a child in spite of their chronic diseases.

Courtesy of the Author

Additionally, acute kidney diseases in pregnancy, from preeclampsia and HELLP syndrome, to acute pyelonephritis and haemolytic uremic syndrome, have not disappeared in developed countries and are a great challenge, and a major cause of death during pregnancy, in the emerging world [3, 4, 5, 6]. The growing awareness of the importance of kidney diseases, beginning in their earliest, non-symptomatic phases, often associated with older age of women giving birth for the first time, and the increased use of assisted fertilisation techniques (often in older women) are factors that have increased the reported incidence and improved the diagnosis of chronic kidney diseases in pregnancy, especially in in the more developed nations [7, 8].

In this context, complex ethical problems may arise from how we define the “maximum” risk at which a patient should be attempt pregnancy, the risk of short- and long-term problems for the infant, given the potentially severe problems linked to prematurity and the higher incidence of metabolic diseases, hypertension, and the possibility of kidney diseases in premature or small for gestational age children [9, 10]. Conversely, the diffusion of nephrology in settings with limited resources, where pregnancy is often the first and only occasion for a timely diagnosis of chronic kidney disease, but where the prevalence of kidney diseases is significantly higher, in particular in the lowest socio-economic strata, highlights need for planning future management, which once more gives rise to controversial practical and ethical issues [3, 11].

Although studies relating to kidney disease in pregnancy are being published more frequently, not all questions have been considered or answered, and clinicians are often challenged by a lack of detailed information and practical guidelines [12].

Thus in this complex, difficult, but also fascinating and evolving panorama, the Journal of Nephrology sought and is publishing this issue dedicated to obstetric nephrology, in an attempt to contribute to the development of this field, with the specific aim of offering practical insights and critical contributions capable of helping clinicians in the management of these “exceptional exceptions”.

The thematic issue will be divided into three main streams:

  • acute kidney diseases in pregnancy, including preeclampsia and its short- and long-term effects on kidney function;

  • chronic kidney diseases in pregnancy, optimally including both their diagnosis and clinical management;

  • ethical issues in obstetric nephrology.

We have invited experts in the field to contribute and also to comment on selected innovative contributions by others and are pleased to inform our readers that the opening paper in the chronic kidney disease stream, on historic moments in the development of obstetric nephrology, will be a contribution by two giants and pioneers in obstetric nephrology, Professors Marshall Lindheimer and John Davison, whose long friendship (over 40 years) also demonstrates the importance of cooperation in new developments in medicine [13, 14, 15].

The acute kidney disease series will start with three contributions from experts working in developed and developing countries, to remind us of the importance of social context in the management and development of these diseases, with one paper on the Italian “best practices” for the management of preeclampsia by the nephrologist, and a physiopathologic reflection on why kidneys may fail post partum.

This issue will contain a variety of articles ranging from treatises on specific topics to case reports that demonstrate a principle or stimulate discussions relevant to management of our patients.

In this same line, we have invited recognized authorities to comment on particular cases, and to give practical examples of the common lines and different approaches to crucial issues such as when to start dialysis in pregnancy, when to perform a kidney biopsy or when and which empiric treatment should be undertaken.

We are also eager to learn from your experience, and we hope that this initiative will also serve to enhance existing collaborations and give rise to new ones, since, especially in developing fields, as the English say, “two heads are better than one”, while according to Spaniards and Italians, “four eyes see more than two”… (Fig. 2).

Fig. 2

Jean Yves Blais: Four eyes see more than two. 2000 about, Sarthe, France. The young playful gipsies are cousins, and were photographed in the same period as the young mother depicted above; one of them recently asked Mr. Blais to make some pictures of his own new-born child. This image, chosen to end our editorial with a smile, is dedicated to the two life-long friends Marshall Lindheimer and John Davison

Acknowledgements

We are deeply thankful to Jean-Yves Blais, for the permission to reproduce his photographs.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

No funding was obtained for this editoral paper.

Ethical approval

This article does not contain any studies with human participants performed by any of the authors.

Copyright information

© Italian Society of Nephrology 2017

Authors and Affiliations

  • Giorgina Barbara Piccoli
    • 1
    • 2
  • Gianfranca Cabiddu
    • 3
  1. 1.Department of Clinical and Biological SciencesUniversity of TorinoTurinItaly
  2. 2.NephrologieCentre Hospitalier Le MansLe MansFrance
  3. 3.NephrologyAzienda Ospedaliera BrotzuCagliariItaly

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