Pregnancy is often described as nature’s “stress test” for women. Although it is a natural physiologic process, it requires a radical recalibration of nearly every organ system, most notably the kidneys. For many women, these 9 months serve as a unique clinical window, revealing underlying vulnerabilities that might otherwise remain hidden for decades. By reframing pregnancy not just as a journey toward motherhood but as a critical diagnostic event, we have a rare opportunity to identify, intercept, and prevent the progression of chronic kidney disease (CKD). In this issue of the Indian Journal of Kidney Disease, Drs Shemies and Naicker review a very relevant issue which concerns women of reproductive age.1 This lucid and very informative article on kidney disease in pregnancy highlights many changes that happen in the nine months in the life a woman. The transient hemodynamic changes during pregnancy actually enhance the physiological functions of the kidney; on the flip side, it also makes the kidneys vulnerable to the slightest of insults.2 The manuscript highlights the various pathological states which can coexist or develop during pregnancy, leading to kidney damage.3 The manuscript also emphasizes the adverse fetal (preterm and low birthweight infants) and maternal outcomes that happen if pregnancy is complicated by kidney disease.4,5 Moreover, as has been appreciated for many years, a small for gestational age child has a higher risk of developing adverse renal and cardiovascular outcomes.6,7 There are clinical reasons for the delayed diagnosis and subsequent inadequate pregnancy care, as the authors clearly explain. The changes in the renal hemodynamics lower the serum creatinine level, and kidney disease is often diagnosed late.8 The classification and staging of CKD based on commonly used equations are not suitable in pregnancy. There are overlapping symptoms and differentiating preeclampsia from worsening CKD is difficult, particularly in mothers in LMICs and LICs who don’t have obstetric follow-up in early pregnancy.9 Mothers in disadvantaged nations also have multiple untreated and undiagnosed comorbidities such as hypertension and diabetes. Moreover, the diagnosis of glomerular diseases during pregnancy is difficult as kidney biopsies are rarely performed during pregnancy because of its attendant risks.10 The authors also contend that the problem of kidney disease is going to increase because of the increasing age at which mothers become pregnant. With the increasing use of various assisted reproductive techniques, more pregnancies will become high-risk for kidney injury. These mothers, such as others in their village/locality, are exposed to multiple local and counterfeit medications. These medications are often nephrotoxic and cause interstitial nephritis. Interstitial nephritis is clinically silent and may complicate pregnancies by worsening kidney injury. Besides the unique clinical issues, there are various healthcare constraints which are equally important in the care of expectant mothers with CKD. Lack of literacy, awareness and easy access to healthcare are often responsible for the mothers to present late to hospitals and clinics. The societal pressures compound delayed access of care, especially in teenage pregnancies. The authors mention about one-third of teenagers become pregnant in Africa.11 Data in other LMICs is believed to be similar where early marriages are quite common. There are challenges in the prevalent health care systems in these countries. Reproductive care is not integrated in the training of internists. Many doctors are not aware about the nuances of reproductive and family-planning choices of women with CKD.12 Nephrologists shy away from discussing reproductive choices with women of reproductive age group and CKD. The concept of multidisciplinary care for complicated pregnancies is nonexistent. A multifaceted and robust obstetric care in high-risk pregnancies in resource-constrained countries is still a dream that is yet to be realized. Along with insufficient infrastructure and lack of access to renal replacement therapy, the challenges of managing pregnancies with CKD continue. High rates of maternal-fetal morbidity (preeclampsia, preterm birth, small for gestational age babies, accelerated kidney function decline in the mother postpartum), late diagnosis, and limited resources plague CKD care in pregnancy within low- and middle-income countries (LMICs).13 This is a “double-barreled” clinical catastrophe where a high incidence of CKD in pregnancy is met with infrastructural constraints. This frequently leads to unforeseen out-of-pocket expenditure, unsustainable, and interrupted care, leading to devastating outcomes. In the article, as mentioned by the authors, Pregnancy-Associated AKI (PRAKI) is a major public health problem in LMICs and LICs, frequently caused by sepsis or obstetric hemorrhage, with a high risk of long-term kidney damage. Although with adequate ante-natal and maternal care, PRAKI is not a significant problem in developed countries, but still contributes to 2%–14% of all acute kidney injury cases in African, Asian and Latin American nations. It is unfortunate that as maternal deaths in complicated pregnancies become rare worldwide, 92% of maternal mortalities occur in LMICs and LICs. Neonates are born with fewer nephrons, increasing their own long-term risk of hypertension and CKD. These common clinical presentations are consequent to underlying poor healthcare facilities and the lack of appropriate antenatal care. Furthermore, women diagnosed with kidney disease often transition to a life of CKD, further straining both personal and governmental resources. Add to the problems of healthcare delivery in pregnant mothers with CKD, there is this “large elephant in the room” of gender inequities in kidney care. There is a paradoxical “gender gap” that women often have a higher prevalence of CKD but are not the preferred sex when it comes to CKD care.14 They are often less represented in dialysis units and face insurmountable barriers while receiving a kidney. In resource-constrained nations, more women donate kidneys compared to those who receive it (the donation paradox)! With this prevailing scenario, there is an opportunity to induct and involve women who have diagnosed with CKD during their pregnancy into various CKD prevention programs. These unfortunate women often enter a cycle of unavoidable, un-booked pregnancies and inevitably progress to kidney failure. Pregnancy is a nature’s test of kidney health.15 Moreover, these women have not been successful in this test. They are as vulnerable to progress to CKD as individuals with other risk factors as diabetes and hypertension. Pregnancy is a window for a woman’s future health. The presence of kidney disease in pregnancy is not only an indicator of underlying kidney pathology but also a predictor of future hypertension and cardiovascular disease.16 Together, with other noncommunicable diseases, governments should also include these women in various NCD programs. All these women should be monitored for regular blood pressure evaluation, kidney function tests and cardiovascular risk assessment. These women should be counselled on diet, exercise, appropriate medication adherence and cessation of other addictions. These interventions can go a long way in reducing the progression of kidney disease. In other instances where these mothers develop PRAKI, a thorough clinical evaluation of these mothers should be done. The authors provide a comprehensive list of conditions during pregnancy which qualifies the mother for long-term care. Various social determinants of health play a major role in the development of acute kidney injury (poverty, environmental pollution, and sanitation). The inclusion of these mothers in health programs will enhance the understanding of the intersectionality of the external milieu and the development of kidney disease.17 Not to forget, the mother on regular follow-up also brings her offspring for regular health check-ups. This not only ensures timely vaccinations and diagnosis of childhood illnesses, but sets up a surveillance program for the future development of hypertension, kidney and cardiovascular disease in these vulnerable children (babies of mothers with kidney disease during pregnancy have a higher incidence of progressive CKD). A major reason as to why kidney disease in pregnancy leads to undesirable feto-maternal outcomes in our part of the world is because of the abiding faith of the society on traditional healers. In the majority of LICs and LMICs, mothers and their families prefer the local healer for their health concerns. These women often receive nephrotoxic medications during their pregnancies.18 These mothers often have their deliveries in the villages in unsanitary and unsupervised conditions. Development of robust culturally sensitive programs which takes care of mothers who had unfortunate pregnancy outcomes because of kidney disease will go a long way in weaning them away from these “healers”. With resource-constrained nations grappling with financial and economic strain taking care of NCDs, the inclusion of mothers with kidney disease in their health programs go a long way in securing their kidney and cardiovascular health. This strategy can improve early detection of CKD, help address barriers and consequently institute comprehensive CKD care Figure 1. Various initiatives at the primary care can create awareness about their underlying medical illness, need for regular follow-up and the therapeutic interventions available to them. Governments and healthcare institutions can strengthen their CKD programs by utilizing the services of para-medical staff, integrating CKD care in ongoing NCD clinics and various antenatal programs.19 This will also help them in future pregnancy planning. These initiatives will also hopefully address the societal pressures that lead to early marriages and teenage pregnancies. The use of point-of-care devices and investigations (urine microscopy) will help in early screening and will be available in remote areas. This, perhaps, is the roadmap for the future for not only mothers whose pregnancies were complicated with kidney disease but for all who carry a high risk of developing CKD.Figure 1: Chronic kidney disease in pregnancy: An opportunity to transcend barriers and develop targeted care
Urmila Anandh (Thu,) studied this question.
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