In Practice Review
Pregnancy and CKD: Advances in Care and the Legacy of Dr Susan Hou

https://doi.org/10.1053/j.ajkd.2021.07.016Get rights and content

Dr Susan Hou began her illustrious nephrology career at a time when pregnancy in women with chronic kidney disease (CKD) was hazardous and actively discouraged. Her pioneering research in women’s health provided much of the early outcome data that shaped our current understanding of CKD and pregnancy. Although many uncertainties regarding optimal management of this vulnerable patient group remain, recent decades have witnessed important advances and renewed interest in improving care for pregnant women with CKD. Many nephrologists have been inspired by Dr Hou’s lifetime of work and are grateful for her generous collaborations. In this In Practice Review, we honor her legacy by providing an update of current literature and clinical management guidance in the context of a clinical case vignette that challenges us to consider the many complex aspects to the counseling and care of women with CKD who desire a pregnancy.

Introduction

An editorial in The Lancet in 1975 noted, “Children of women with renal disease used to be born dangerously or not at all—not at all if their doctors had their way.”1 Fortunately, within a decade, Dr Susan Hou began her illustrious nephrology career pioneering research in women’s health. She was responsible for much of the early outcome data that has shaped our understanding of chronic kidney disease (CKD) and pregnancy, informing clinical care facilitated by shared decision-making. Although there are still many uncertainties regarding optimal management of this vulnerable patient group, recent decades have witnessed important advances and renewed interest in improving care for pregnant women with CKD. Many nephrologists are grateful for Dr Hou’s generous collaborations and are inspired by her lifetime’s work, even those who joined the field subsequent to her death on July 27, 2019. In this review, we honor her legacy by providing an update of current literature and knowledge in the context of a clinical case vignette that challenges us to consider the many complex aspects to the counseling and care of women with CKD who desire a family.

Section snippets

Clinical Vignette

A 30-year-old woman with chronic kidney disease (CKD) stage 3b with an estimated glomerular filtration rate (eGFR) of 32 mL/min/1.73 m2 and urinary protein-creatinine ratio of 0.4 g/g due to lupus nephritis is seen in clinic for routine follow-up. She was diagnosed with World Health Organization class IV lupus nephritis 5 years earlier, at which time she presented with a serum creatinine level (Scr) of 2.2 mg/dL and a urinary protein-creatinine ratio of 3.1 g/g. Kidney biopsy showed

Sexual and Reproductive Health of Women With CKD

Historically, the reproductive health care needs of women with CKD have been overlooked and underserved. Survey studies suggest that nephrologists recognize the impact and importance of sexual and reproductive health in patients with CKD, but do not frequently address these concerns or feel confident managing them.2, 3, 4 Social, political, economic, and medical factors all play roles in the differences women experience in achieving autonomy in their reproductive health.5 Women with CKD face

Management of CKD in Pregnancy

In general, for pregnant women with CKD, we recommend coordinated care with high-risk obstetricians with a plan for delivery at a center with a neonatal intensive care unit. Visit and laboratory monitoring frequency will vary by severity of the underlying CKD and associated comorbidities, but we routinely see patients at least once in the first trimester, one or two times in the second trimester, and as often as weekly in the third trimester to manage blood pressure and other medications,

Managing Pregnancy With Kidney Replacement Therapy

An increasing serum β-human chorionic gonadotropin hormone level and an intrauterine gestational sac on ultrasound confirm pregnancy in anuric women. In 1998, Dr Hou and colleagues reported a trend toward better infant survival in women who received at least 20 hours per week of dialysis while pregnant.72 Since then, observational studies have shown improvement in live birth rates, gestational age, and birth weight with an intensified hemodialysis strategy:73, 74, 75 We increase the intensity

Advances and Future Care

Dr Hou was a pioneer and expert in kidney disease and pregnancy. During her career, spanning 3 decades, she made many contributions that improved obstetric care. Through her work and that of others, we have gained a better understanding of pregnancy-associated progression of CKD, neonatal outcomes, and risk factors for adverse outcomes such as chronic hypertension and a lack of compensatory decrease in Scr in pregnancy.30 Future work should further refine our understanding of

Article Information

Authors’ Full Names and Academic Degrees

Andrea L. Oliverio, MD, MSc, Kate Bramham, MBBS, PhD, and Michelle A. Hladunewich, MD, MSc.

Support

Dr Oliverio was supported by National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) grant K23 DK123413-01.

Financial Disclosure

Dr Hladunewich declares a grant from Roche Pharmaceuticals to study preeclampsia biomarkers in pregnant women with CKD. The remaining authors declare that they have no relevant financial interests.

Peer Review

Received March 21, 2021, in response to an invitation from the journal. Evaluated by 2

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