1) This study conducted a systematic review and meta-analysis of 23 studies to examine the effects of chronic kidney disease (CKD) on pregnancy outcomes and the effects of pregnancy on renal outcomes in women with CKD.
2) The results showed that women with CKD faced significantly higher risks of adverse pregnancy outcomes like preeclampsia, premature birth, and small-for-gestational-age babies compared to women without CKD.
3) However, the study found no evidence that pregnancy led to worsening of renal outcomes in women with CKD compared to non-pregnant women with CKD. Pregnancy did not appear to negatively impact kidney function or progression to kidney failure.
This document discusses various topics related to renal physiology and disease in pregnancy. It begins with an overview of the normal adaptations the kidneys undergo during pregnancy, including increases in kidney size, glomerular filtration rate (GFR), and decreased creatinine and blood urea nitrogen levels. It then covers specific topics like urinary tract infections (UTIs), hypertensive disorders of pregnancy, acute kidney injury, and chronic kidney disease in the context of pregnancy. For each topic, it provides details on pathogenesis, screening, treatment approaches, and management considerations for caring for pregnant patients with renal conditions.
Dr Abdullah Ansari
MBBS, MD Medicine
Aligarh Muslim University
Physiological changes during pregnancy
Systemic changes
Renal changes
Renal function
Tubular function
Plasma osmolality
Anatomical changes
AKI during pregnancy
Pre-renal causes
Renal causes
Post-renal causes
Investigations
Management
This document provides an overview of acute kidney injury (AKI) in pregnancy. It discusses the definition of AKI in pregnancy, epidemiology, physiologic changes during pregnancy that impact the kidneys, common etiologies of AKI including preeclampsia, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome. It also covers the diagnostic approach, differential diagnosis, and treatment considerations for AKI in pregnancy.
This document discusses dengue fever, including its prevalence, transmission, clinical presentation, diagnosis, and management, with a focus on dengue in pregnancy. It notes that 40% of the world's population lives in dengue-prone areas and there are an estimated 100 million infections annually. Early detection and medical care reduces the fatality rate from 20% to below 1%. The document outlines the warning signs of severe dengue, diagnostic tests, fluid resuscitation protocols, and emphasizes the importance of prompt diagnosis and management to reduce morbidity and mortality in both mothers and infants.
Ovarian reserve refers to the reproductive potential left within a woman's two ovaries based on number and quality of eggs. Diminished ovarian reserve is the loss of normal reproductive potential in the ovaries due to a lower count or quality of the remaining eggs
Gawad-Pregnancy in Pre-Existing Kidney Disease, DNG, 31 Jan 2016FarragBahbah
Mohammed Abdel Gawad is a nephrology specialist who provides care for pregnancy in pre-existing kidney disease. His document outlines general principles of prenatal care including maintaining blood pressure between 110-140/80-90 mmHg, hemoglobin between 10-11 g/dL, daily folic acid, low-dose aspirin, heparin, and a protein diet. He also discusses assessing fetal well-being, identifying urinary tract infections and superimposed preeclampsia. A multidisciplinary team approach including obstetricians, nephrologists and neonatologists is recommended for managing the complexities of pregnancy with pre-existing kidney disease.
This document summarizes the role of progesterone in different contexts. It discusses how progesterone prepares the endometrium for implantation and supports early pregnancy. It reviews evidence from meta-analyses and clinical trials on the use of progesterone to prevent miscarriage in women with recurrent miscarriage, finding a beneficial effect. The document also examines evidence related to progesterone supplementation for luteal phase support in IVF cycles and for treating threatened abortion, finding current evidence is limited and more research is still needed.
This document discusses various topics related to renal physiology and disease in pregnancy. It begins with an overview of the normal adaptations the kidneys undergo during pregnancy, including increases in kidney size, glomerular filtration rate (GFR), and decreased creatinine and blood urea nitrogen levels. It then covers specific topics like urinary tract infections (UTIs), hypertensive disorders of pregnancy, acute kidney injury, and chronic kidney disease in the context of pregnancy. For each topic, it provides details on pathogenesis, screening, treatment approaches, and management considerations for caring for pregnant patients with renal conditions.
Dr Abdullah Ansari
MBBS, MD Medicine
Aligarh Muslim University
Physiological changes during pregnancy
Systemic changes
Renal changes
Renal function
Tubular function
Plasma osmolality
Anatomical changes
AKI during pregnancy
Pre-renal causes
Renal causes
Post-renal causes
Investigations
Management
This document provides an overview of acute kidney injury (AKI) in pregnancy. It discusses the definition of AKI in pregnancy, epidemiology, physiologic changes during pregnancy that impact the kidneys, common etiologies of AKI including preeclampsia, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome. It also covers the diagnostic approach, differential diagnosis, and treatment considerations for AKI in pregnancy.
This document discusses dengue fever, including its prevalence, transmission, clinical presentation, diagnosis, and management, with a focus on dengue in pregnancy. It notes that 40% of the world's population lives in dengue-prone areas and there are an estimated 100 million infections annually. Early detection and medical care reduces the fatality rate from 20% to below 1%. The document outlines the warning signs of severe dengue, diagnostic tests, fluid resuscitation protocols, and emphasizes the importance of prompt diagnosis and management to reduce morbidity and mortality in both mothers and infants.
Ovarian reserve refers to the reproductive potential left within a woman's two ovaries based on number and quality of eggs. Diminished ovarian reserve is the loss of normal reproductive potential in the ovaries due to a lower count or quality of the remaining eggs
Gawad-Pregnancy in Pre-Existing Kidney Disease, DNG, 31 Jan 2016FarragBahbah
Mohammed Abdel Gawad is a nephrology specialist who provides care for pregnancy in pre-existing kidney disease. His document outlines general principles of prenatal care including maintaining blood pressure between 110-140/80-90 mmHg, hemoglobin between 10-11 g/dL, daily folic acid, low-dose aspirin, heparin, and a protein diet. He also discusses assessing fetal well-being, identifying urinary tract infections and superimposed preeclampsia. A multidisciplinary team approach including obstetricians, nephrologists and neonatologists is recommended for managing the complexities of pregnancy with pre-existing kidney disease.
This document summarizes the role of progesterone in different contexts. It discusses how progesterone prepares the endometrium for implantation and supports early pregnancy. It reviews evidence from meta-analyses and clinical trials on the use of progesterone to prevent miscarriage in women with recurrent miscarriage, finding a beneficial effect. The document also examines evidence related to progesterone supplementation for luteal phase support in IVF cycles and for treating threatened abortion, finding current evidence is limited and more research is still needed.
This document discusses the challenges of caring for elderly patients with end-stage renal disease (ESRD). It notes that the population is aging rapidly worldwide, increasing the number of elderly patients with kidney disease and ESRD. Caring for elderly ESRD patients is complex due to multiple age-related physiological changes in kidney function as well as high rates of comorbidities. The document advocates for a multidisciplinary approach to care that considers patients' medical, cognitive, functional, and palliative care needs in making treatment decisions for this complex patient population.
This document discusses fertility and pregnancy outcomes in kidney transplant recipients. It notes that fertility usually returns within months of transplantation as endocrine function improves. Successful pregnancies are possible if pre-pregnancy renal function is stable, with live birth rates around 73.5% and risks of preeclampsia and preterm delivery elevated compared to the general population. Immunosuppressant use requires careful management due to risks of rejection and fetal exposure. Pregnancy is considered low risk if renal function is optimal and dosing is stable for over 12 months after transplantation.
acute kidney injury during pregnancy, challenges in diagnosis and treatmentMarwa Elkaref
This document discusses acute kidney injury (AKI) during pregnancy. It begins by explaining the physiological changes in pregnancy that make diagnosing AKI difficult. It then discusses the causes and classifications of AKI during pregnancy. Some key causes mentioned include preeclampsia, HELLP syndrome, and septic abortion. The document outlines supportive management of renal function as well as treating the underlying disease. It notes that dialysis may be needed if other procedures are insufficient.
Renal changes during pregnancy include:
1. Structural changes such as increased kidney size and volume due to vascular and interstitial fluid changes.
2. Systemic changes including resetting of osmoregulation and volume regulation set points to accommodate increased plasma volume. Hormonal changes like increased progesterone, relaxin, and erythropoietin also impact renal function.
3. Renal hemodynamic changes with glomerular filtration rate increasing up to 50% in the first trimester due to reduced oncotic pressure and increased ultrafiltration capacity, remaining elevated through pregnancy.
The document discusses physiological changes during pregnancy that affect the kidneys. There is an increase in glomerular filtration rate and renal plasma flow by 50-60% due to rising plasma volume. Intraglomerular blood pressure remains unchanged despite these changes. Common renal complications in pregnancy include urinary tract infections, preeclampsia, acute renal failure, and renal calculi. Pregnancy poses risks but can be managed for women with pre-existing kidney disease through monitoring and adjusting treatment as needed.
LETROZOLE - A WONDER DRUG FOR OVULATION INDUCTION BY DR SHASHWAT JANIDR SHASHWAT JANI
Letrozole is an aromatase inhibitor that has been used as an alternative to clomiphene citrate for ovulation induction in women with infertility. It works by inhibiting the aromatase enzyme, reducing estrogen levels and allowing for increased FSH production and dominant follicle development. Studies have shown letrozole to be as effective as clomiphene citrate in ovulation and pregnancy rates. While initial studies raised safety concerns for babies exposed to letrozole, larger subsequent studies found no increased risk of birth defects compared to clomiphene citrate or the general population. Letrozole is now a widely accepted treatment for ovulation induction and infertility.
Luteal Phase Defect Contributors Dr.Shweta Mittal Gupta & DGF Team Experts Lifecare Centre
This document discusses luteal phase defect (LPD), including its definition, causes, diagnosis, and treatment. Some key points:
- LPD is defined as a luteal phase that is not capable of implantation or maintaining pregnancy, and can be caused by issues with folliculogenesis, the LH surge, or progesterone production/response.
- It affects 4.4% of fertile populations and 3.5-13% of infertile patients, and as high as 32-35% of recurrent miscarriage cases.
- Diagnosis involves timed endometrial biopsies or progesterone level testing, though single tests have limitations. Treatment involves addressing underlying causes like hyperprolactinemia and
Management of SLE with pregnancy ,the difficult missionWafaa Benjamin
Involvement of obstetricians and physicians with experience of managing SLE in pregnancy improves the outcome for the mother and foetus.
MDT
Pre-pregnancy clinics
Triage of low& high risk women
Be alert to detect a flare
Wait for PE & distinguish from L.nephritis
TOP when in risk
Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
Kisspeptin has emerged as a key regulator of the reproductive axis. It stimulates GnRH secretion and plays an important role in puberty, fertility, and pregnancy. Kisspeptin signaling is regulated by factors like leptin and nutritional status. Mutations in kisspeptin or its receptor can cause hypogonadism or precocious puberty in humans. Exogenous kisspeptin administration stimulates gonadotropin release and has potential applications in treating infertility, inducing final oocyte maturation in IVF, and as a safer alternative to hCG for triggering ovulation.
1. Selective progesterone receptor modulators (SPRMs) are a class of drugs that act as agonists or antagonists of the progesterone receptor in a tissue-selective manner.
2. Several SPRMs are discussed in the document, including mifepristone, ulipristal acetate, telapristone, and asoprisnil, which are being studied for uses like emergency contraception and treatment of uterine fibroids.
3. Clinical trials have compared the effectiveness of different SPRMs to other medications for emergency contraception and found them to be similarly effective while also having fewer side effects in some cases. SPRMs are also being researched for their potential mechanisms of action and effects on tissues like
The document discusses hypertensive disorders of pregnancy, which are a leading cause of maternal mortality. Gestational hypertension and preeclampsia are characterized by high blood pressure and proteinuria developing after 20 weeks of pregnancy. Preeclampsia can progress to eclampsia, which involves seizures. Risk factors include nulliparity, obesity, and family history. Symptoms include headaches and visual changes. Complications affect both mother and baby. Treatment involves controlling blood pressure, delivering the baby, and administering magnesium sulfate to prevent seizures.
This document provides information about Dr. Laxmi Shrikhande's credentials and experience in gynecology and fertility. It then summarizes guidelines for assessing and managing polycystic ovary syndrome (PCOS) and infertility. Key recommendations include using letrozole as first-line pharmacological treatment for infertility in PCOS patients, and considering gonadotropins as second-line if letrozole fails. The risks of ovarian hyperstimulation syndrome are also discussed for PCOS patients undergoing fertility treatments like IVF.
This document discusses the challenges of systemic lupus erythematosus (SLE) in pregnancy. It notes that SLE can increase risks of miscarriage, fetal growth restriction, and complications. It emphasizes the importance of pre-pregnancy planning and consultation to determine risk factors like autoantibodies. Ongoing monitoring during pregnancy is needed to watch for flares in the mother's condition or issues in fetal development. Medications may need adjusting to balance disease management and fetal safety.
The document discusses progestogens, which include progesterone and synthetic progestins. Progesterone is secreted naturally, while progestins have progesterone-like effects. Both are used for obstetric and gynecologic purposes. Therapeutically, progestogens are used to support early pregnancy, treat menstrual disorders, provide luteal phase support in assisted reproduction, and relieve symptoms of conditions like endometriosis. While generally effective, studies on uses like threatened miscarriage and preterm labor have been limited by small sample sizes. Natural progesterone generally has fewer side effects than progestins. The document examines various progestogen types and routes of administration.
A COMPARATIVE ANALYSIS OF HEMATOLOGICAL INDICES IN PREGNANT WOMEN AND NON PR...FidelityP
Red blood cell (RBC) indices are individual components of a routine blood test called the complete blood count (CBC). The CBC is used to measure the quantity and physical characteristics of different types of cells found in your blood. Blood consists of RBCs, white blood cells (WBCs), and platelets that are suspended in your plasma. Platelets are cells that enable clot formation. RBCs contain hemoglobin, which carries oxygen throughout your body to all of your tissues and organs. An RBC is pale red and gets its color from hemoglobin. It’s shaped like a doughnut, but it has a thinner area in the middle instead of a hole. Your RBCs are normally all the same color, size, and shape. However, certain conditions can cause variations that impair their ability to function properly. The RBC indices measure the size, shape, and physical characteristics of the RBCs. Your doctor can use RBC indices to help diagnose the cause of anemia. Anemia is a common blood disorder in which you have too few, misshapen, or poorly functional RBCs123
This document provides information on contraceptive counseling for patients with hypertension. It outlines the components of a contraceptive counseling visit including taking a medical history, physical exam, and discussing options based on health risks. A case study is presented of a 24 year old female with hypertension, chest pain, and a BMI of 57 who desires depo-provera. The document determines depo is not recommended due to her cardiovascular risks and suggests IUDs or nexplanon as safer options given her upcoming weight loss surgery. Guidelines for contraceptive use in hypertension are reviewed recommending against combined hormonal methods and considering patient's blood pressure levels and cardiovascular risk factors when selecting contraception.
This document discusses the challenges of caring for elderly patients with end-stage renal disease (ESRD). It notes that the population is aging rapidly worldwide, increasing the number of elderly patients with kidney disease and ESRD. Caring for elderly ESRD patients is complex due to multiple age-related physiological changes in kidney function as well as high rates of comorbidities. The document advocates for a multidisciplinary approach to care that considers patients' medical, cognitive, functional, and palliative care needs in making treatment decisions for this complex patient population.
This document discusses fertility and pregnancy outcomes in kidney transplant recipients. It notes that fertility usually returns within months of transplantation as endocrine function improves. Successful pregnancies are possible if pre-pregnancy renal function is stable, with live birth rates around 73.5% and risks of preeclampsia and preterm delivery elevated compared to the general population. Immunosuppressant use requires careful management due to risks of rejection and fetal exposure. Pregnancy is considered low risk if renal function is optimal and dosing is stable for over 12 months after transplantation.
acute kidney injury during pregnancy, challenges in diagnosis and treatmentMarwa Elkaref
This document discusses acute kidney injury (AKI) during pregnancy. It begins by explaining the physiological changes in pregnancy that make diagnosing AKI difficult. It then discusses the causes and classifications of AKI during pregnancy. Some key causes mentioned include preeclampsia, HELLP syndrome, and septic abortion. The document outlines supportive management of renal function as well as treating the underlying disease. It notes that dialysis may be needed if other procedures are insufficient.
Renal changes during pregnancy include:
1. Structural changes such as increased kidney size and volume due to vascular and interstitial fluid changes.
2. Systemic changes including resetting of osmoregulation and volume regulation set points to accommodate increased plasma volume. Hormonal changes like increased progesterone, relaxin, and erythropoietin also impact renal function.
3. Renal hemodynamic changes with glomerular filtration rate increasing up to 50% in the first trimester due to reduced oncotic pressure and increased ultrafiltration capacity, remaining elevated through pregnancy.
The document discusses physiological changes during pregnancy that affect the kidneys. There is an increase in glomerular filtration rate and renal plasma flow by 50-60% due to rising plasma volume. Intraglomerular blood pressure remains unchanged despite these changes. Common renal complications in pregnancy include urinary tract infections, preeclampsia, acute renal failure, and renal calculi. Pregnancy poses risks but can be managed for women with pre-existing kidney disease through monitoring and adjusting treatment as needed.
LETROZOLE - A WONDER DRUG FOR OVULATION INDUCTION BY DR SHASHWAT JANIDR SHASHWAT JANI
Letrozole is an aromatase inhibitor that has been used as an alternative to clomiphene citrate for ovulation induction in women with infertility. It works by inhibiting the aromatase enzyme, reducing estrogen levels and allowing for increased FSH production and dominant follicle development. Studies have shown letrozole to be as effective as clomiphene citrate in ovulation and pregnancy rates. While initial studies raised safety concerns for babies exposed to letrozole, larger subsequent studies found no increased risk of birth defects compared to clomiphene citrate or the general population. Letrozole is now a widely accepted treatment for ovulation induction and infertility.
Luteal Phase Defect Contributors Dr.Shweta Mittal Gupta & DGF Team Experts Lifecare Centre
This document discusses luteal phase defect (LPD), including its definition, causes, diagnosis, and treatment. Some key points:
- LPD is defined as a luteal phase that is not capable of implantation or maintaining pregnancy, and can be caused by issues with folliculogenesis, the LH surge, or progesterone production/response.
- It affects 4.4% of fertile populations and 3.5-13% of infertile patients, and as high as 32-35% of recurrent miscarriage cases.
- Diagnosis involves timed endometrial biopsies or progesterone level testing, though single tests have limitations. Treatment involves addressing underlying causes like hyperprolactinemia and
Management of SLE with pregnancy ,the difficult missionWafaa Benjamin
Involvement of obstetricians and physicians with experience of managing SLE in pregnancy improves the outcome for the mother and foetus.
MDT
Pre-pregnancy clinics
Triage of low& high risk women
Be alert to detect a flare
Wait for PE & distinguish from L.nephritis
TOP when in risk
Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
Kisspeptin has emerged as a key regulator of the reproductive axis. It stimulates GnRH secretion and plays an important role in puberty, fertility, and pregnancy. Kisspeptin signaling is regulated by factors like leptin and nutritional status. Mutations in kisspeptin or its receptor can cause hypogonadism or precocious puberty in humans. Exogenous kisspeptin administration stimulates gonadotropin release and has potential applications in treating infertility, inducing final oocyte maturation in IVF, and as a safer alternative to hCG for triggering ovulation.
1. Selective progesterone receptor modulators (SPRMs) are a class of drugs that act as agonists or antagonists of the progesterone receptor in a tissue-selective manner.
2. Several SPRMs are discussed in the document, including mifepristone, ulipristal acetate, telapristone, and asoprisnil, which are being studied for uses like emergency contraception and treatment of uterine fibroids.
3. Clinical trials have compared the effectiveness of different SPRMs to other medications for emergency contraception and found them to be similarly effective while also having fewer side effects in some cases. SPRMs are also being researched for their potential mechanisms of action and effects on tissues like
The document discusses hypertensive disorders of pregnancy, which are a leading cause of maternal mortality. Gestational hypertension and preeclampsia are characterized by high blood pressure and proteinuria developing after 20 weeks of pregnancy. Preeclampsia can progress to eclampsia, which involves seizures. Risk factors include nulliparity, obesity, and family history. Symptoms include headaches and visual changes. Complications affect both mother and baby. Treatment involves controlling blood pressure, delivering the baby, and administering magnesium sulfate to prevent seizures.
This document provides information about Dr. Laxmi Shrikhande's credentials and experience in gynecology and fertility. It then summarizes guidelines for assessing and managing polycystic ovary syndrome (PCOS) and infertility. Key recommendations include using letrozole as first-line pharmacological treatment for infertility in PCOS patients, and considering gonadotropins as second-line if letrozole fails. The risks of ovarian hyperstimulation syndrome are also discussed for PCOS patients undergoing fertility treatments like IVF.
This document discusses the challenges of systemic lupus erythematosus (SLE) in pregnancy. It notes that SLE can increase risks of miscarriage, fetal growth restriction, and complications. It emphasizes the importance of pre-pregnancy planning and consultation to determine risk factors like autoantibodies. Ongoing monitoring during pregnancy is needed to watch for flares in the mother's condition or issues in fetal development. Medications may need adjusting to balance disease management and fetal safety.
The document discusses progestogens, which include progesterone and synthetic progestins. Progesterone is secreted naturally, while progestins have progesterone-like effects. Both are used for obstetric and gynecologic purposes. Therapeutically, progestogens are used to support early pregnancy, treat menstrual disorders, provide luteal phase support in assisted reproduction, and relieve symptoms of conditions like endometriosis. While generally effective, studies on uses like threatened miscarriage and preterm labor have been limited by small sample sizes. Natural progesterone generally has fewer side effects than progestins. The document examines various progestogen types and routes of administration.
A COMPARATIVE ANALYSIS OF HEMATOLOGICAL INDICES IN PREGNANT WOMEN AND NON PR...FidelityP
Red blood cell (RBC) indices are individual components of a routine blood test called the complete blood count (CBC). The CBC is used to measure the quantity and physical characteristics of different types of cells found in your blood. Blood consists of RBCs, white blood cells (WBCs), and platelets that are suspended in your plasma. Platelets are cells that enable clot formation. RBCs contain hemoglobin, which carries oxygen throughout your body to all of your tissues and organs. An RBC is pale red and gets its color from hemoglobin. It’s shaped like a doughnut, but it has a thinner area in the middle instead of a hole. Your RBCs are normally all the same color, size, and shape. However, certain conditions can cause variations that impair their ability to function properly. The RBC indices measure the size, shape, and physical characteristics of the RBCs. Your doctor can use RBC indices to help diagnose the cause of anemia. Anemia is a common blood disorder in which you have too few, misshapen, or poorly functional RBCs123
This document provides information on contraceptive counseling for patients with hypertension. It outlines the components of a contraceptive counseling visit including taking a medical history, physical exam, and discussing options based on health risks. A case study is presented of a 24 year old female with hypertension, chest pain, and a BMI of 57 who desires depo-provera. The document determines depo is not recommended due to her cardiovascular risks and suggests IUDs or nexplanon as safer options given her upcoming weight loss surgery. Guidelines for contraceptive use in hypertension are reviewed recommending against combined hormonal methods and considering patient's blood pressure levels and cardiovascular risk factors when selecting contraception.
This document presents a study proposal on assessing the effectiveness of nursing care in reducing blood sugar levels among pregnant women with gestational diabetes mellitus. The study aims to compare blood sugar levels between an experimental group that receives nursing care and a control group. The introduction provides background on gestational diabetes and its risks. The methodology will use a quasi-experimental design with 60 subjects divided into experimental and control groups. Nursing care involving education will be provided to the experimental group for 5 days. Blood sugar levels will be measured before and after the intervention to analyze its effectiveness. Appropriate statistical tests will be used to analyze the results.
This study evaluated the clinical and perinatal outcomes of 100 teenage pregnancies at a tertiary referral center in South India. The study found that teenage pregnancies had higher rates of complications like anemia (43%), preeclampsia (21%), preterm labor (21%), and emergency c-sections (33%) compared to adult pregnancies. Neonatal outcomes were also worse, with 38% of babies being low birth weight (<2.5 kg) and 21% being preterm. The study concluded that teenage pregnancy poses significant health risks to both mother and baby due to the biological immaturity of teenage mothers.
Choosing Wisely: 15 Things Physicians and Patients Should QuestionVõ Tá Sơn
This document provides 15 recommendations for clinical practices that should be questioned in obstetrics based on a lack of evidence of benefit or potential for harm. Specifically, it recommends against: performing inherited thrombophilia evaluations; placing cerclages in twin pregnancies; offering noninvasive prenatal testing to low-risk patients; screening for intrauterine growth restriction with Doppler; using progestogens for multifetal gestations; and several other prenatal tests and interventions when scientific evidence is lacking. The recommendations are intended to discourage common practices that have not been shown to meaningfully improve outcomes.
Small for gestational age (SGA) is usually defined as an infant with a birthweight <10th centile for a population or customized standard. Fetal growth restriction refers to a fetus that has failed to reach its biological growth potential because of placental dysfunction. This document reviews 6 national guidelines on the management of SGA/FGR published from 2010 onwards. There is general consensus between guidelines on definitions of SGA and FGR, screening and prevention approaches like risk assessment and smoking cessation. However, guidelines vary in recommendations for ultrasound surveillance frequency after diagnosis and optimal timing of delivery for early or late onset SGA/FGR.
Esta es la actualización sobre criterios y manejo de Sindrome Hipertensivo del embarazo que se han comenzado a usar este año.
Publicación actualmente no liberada.
Nuevos criterios diagnósticos de preeclampsia
Actualización 2013-2014 de sindrome hipertensivo del embarazo ACOG
Hypertensionin pregnancy ACOG Actualización Diciembre 2013
This study estimated the prevalence of chronic kidney disease (CKD) among 132 patients attending a diabetes clinic in Jamaica. Approximately 86% of patients had CKD based on estimated glomerular filtration rate (eGFR) below 60 or albuminuria of 30 mg/g or higher. Over 20% had moderate albuminuria and 62% had severe albuminuria. Based on risk categories from the KDIGO guidelines, 51% were at high risk and 17% at very high risk of adverse outcomes like mortality, cardiovascular disease, and kidney failure. The high prevalence of CKD and risk of adverse outcomes shows the need for further studies on preventing CKD in diabetes patients in developing countries.
Novel Approach Of Diabetes Disease Classification By Support Vector Machine W...IJARIIT
Early diagnosis of any disease with less cost is always preferable. Diabetes is one such disease. It has become the fourth leading cause of death in developed countries and is also reaching epidemic proportions in many developing and newly industrialized nations. Diabetes leads to increase in the risks of developing kidney disease, blindness, nerve damage, blood vessel damage and heart disease also. In this study, we investigate an automatic approach to diagnose Diabetes disease based on Bacterial Foraging Optimization and Artificial Neural Network .firstly, we applied Bacterial Foraging Optimization for features selection and then we implement artificial neural network for finding out the classification accuracy. The proposed SVM method obtains 87.23% accuracy on UCI diabetes dataset which is better than other models.
Secondly, we applied again Bacterial foraging optimization for features selection and then we applied support vector machine for finding out the classification accuracy .The proposed Correlation with SVM method obtains on UCI dataset.
This journal club presentation summarized a study on the relationship between obesity and the severity of non-alcoholic fatty liver disease (NAFLD). The presentation included:
- An overview of the systematic review and meta-analysis that examined 13 studies with over 11,000 NAFLD patients to compare clinical features between non-obese and obese NAFLD.
- Key results showing obesity was associated with higher liver enzymes and inflammation scores, but not higher NAFLD activity scores or prevalence of NASH. Obesity was also correlated with increased liver fibrosis in NAFLD patients.
- The methodology involved assessing study quality, extracting data on patient characteristics and outcomes, and using statistical analyses to evaluate differences between
BIRTH WEIGHT,CURRENT WEIGHT,WEIGHT DYNAMISM FROM BIRTH TO ADULTHOOD.pptxSadanand Indi
This study aimed to assess the significance of birth weight and weight dynamism from birth to adulthood in correlating with heart failure. It found that patients with heart failure had significantly lower mean birth weight compared to controls without heart failure. A higher proportion of heart failure patients also had low birth weight. Additionally, heart failure patients tended to be overweight or obese in adulthood compared to normal weight controls. Thus low birth weight and excess weight gain over life course were associated with greater risk of heart failure.
The document provides an executive summary of recommendations from the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Key points include:
1) Hypertensive disorders of pregnancy remain a major health issue and can cause serious maternal-fetal morbidity and mortality.
2) The task force reviewed evidence and provides guidelines for classifying, diagnosing, predicting, preventing, and managing hypertension during pregnancy, including preeclampsia.
3) Recommendations address topics like low-dose aspirin prevention for high risk women, monitoring and treatment approaches, and emphasize that preeclampsia is a progressive condition that can worsen rapidly.
RunningHead: PICOT Question 1
RunningHead: PICOT Question 7
PICOT Question
Avery Bryan
NRS-433V
Professor Christine Vannelli
May 19, 2019
Clinical Problem
A report from the Center for Disease Control and Prevention in 2015 revealed that (9.4%) 30.3 million Americans are diabetic and 84.1 million have prediabetes. This is a total population of over 100 million is at risk of developing type 2 diabetes which is a growing health problem being the seventh leading cause of death in the U.S. An estimated 1.5 million new cases were among 18-year old bracket and the rates of diagnosed diabetes increased proportionally to age. Below 44 years accounted for 4%, below 64 years at 17 % and 25% for those above 65 years across both genders. One-third of adults in America has prediabetes but sadly, they are unaware despite reports released by The National Diabetes Statistics Report every year. These reports elaborate on prevalence and incidence, prediabetes, long-term complications, risk factors, mortality, and cost. Diabetes poses the risk of serious complications like death, blindness, stroke, kidney disorders, cardiac diseases and health problems that lead to amputation of legs. However, the risks can be mitigated through physical body activities, proper dieting and prescribed use of insulin and other related measures to control the blood sugar levels. Diabetes Prevention Program was funded by NIH to research a yearly evidence-based program to improve healthy weight loss through diet and physical activities. There also efforts to determine the effectiveness of public service campaigns in improving the real-life experience in the diagnosis and treatment of diabetes.
PICOT Question.
The population affected by diabetes cuts across all ages, gender, race, and ethnicity. The prevalence is significantly high from 18 years and it increases with age to about 25% above 65 years. In terms of gender, men are at higher risk accounting for 37% while women are at 30% across races and educational levels. On races, the rates were higher among Indians/Alaska natives at 15%, non-Hispanic blacks at 12.7% and Hispanics at 12%. Among Asians, the rates were lower at 8% and 7.4% for non-Hispanic whites.
Intervention indicator for diabetes shows that individuals who do not observe a healthy diet are more exposed to the disease. Some risk behaviors include lack of exercise and excessive intake of junk foods that lead to obesity and increased blood sugar levels. Diabetes prevalence varied according to education levels were those with less than high school education at 12.6% and 7.2% for those higher than high school education.
Comparison and use of a control group from the popularity of Complementary and Alternative Medicine and Traditional Chinese Medicine showed distinct knowledge of diabetes, blood sugar control, and self-care. The experimental group received education through interactive multimedia for three months while the control group received.
Hypertension (66%) and diabetes (22%) were the most common risk factors for chronic kidney disease (CKD) in patients studied. The majority of patients were male (70%), from rural areas (66%), and in the 41-60 age group (52%). Most patients presented with advanced CKD (stages 3, 4, and 5) and complications such as anemia (76%), cardiovascular issues (18%), and fluid overload symptoms (38% with pedal edema). Better control of hypertension and diabetes is needed to prevent CKD progression, as 18% of diabetics and 21% of hypertensives studied were not well-controlled. More community screening and awareness of risks like analgesic overuse could help detect C
Peripartum cardiomyopathy (PPCM) is heart failure that develops in the final month of pregnancy or within 5 months after delivery. It is defined by the presence of left ventricular systolic dysfunction without an identifiable cause. The cause is unknown but may involve hormonal and genetic factors. Symptoms include those of heart failure like shortness of breath. Treatment focuses on heart failure management. Prognosis is generally good, with around 70% of patients recovering heart function within 6 months though those with more severe dysfunction have a lower recovery rate.
International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
The Relationship between Maternal Anemia and Birth Weight in New Borniosrjce
This study examined the relationship between maternal anemia and birth weight in newborns delivered at a hospital in Karaikal, India between January 2014 and December 2014. The study included 1182 pregnant women, of which 924 (78%) were anemic (hemoglobin <11g/dL) and 258 (22%) were not anemic. The study found no correlation between maternal anemia and low birth weight in newborns. However, operative deliveries (C-sections) tended to be higher for anemic mothers compared to non-anemic mothers. While some previous studies have found an association between maternal anemia and increased risk of low birth weight and C-sections, this study did
This study examined perinatal outcomes in 131 pregnancies among women with sickle cell disease (SCD) receiving care at a hospital in London between 2007-2017. The pregnancies of women with SCD were matched to 1310 unaffected pregnancies based on ethnicity and year of delivery. The study found higher risks of stillbirth, preeclampsia, preterm birth, and admission to the neonatal unit among pregnancies of women with SCD compared to unaffected pregnancies, after adjusting for maternal characteristics. Limitations included limited power to examine associations with maternal and fetal mortality and lack of data for some outcomes in the comparison group.
Sunitinib for the pancreatic neuroendocrine tumors, Moh'd sharshirMoh'd sharshir
1) Pancreatic neuroendocrine tumors are rare tumors that arise in the pancreas and often spread to the liver. Surgery is the primary treatment but many tumors are inoperable or metastasize.
2) The study examined using the drug sunitinib to treat advanced pancreatic neuroendocrine tumors, as these tumors rely on angiogenesis facilitated by growth factors like VEGF.
3) In a phase 3 clinical trial, 171 patients were randomized to receive either sunitinib or a placebo pill daily. Sunitinib was shown to significantly extend progression-free survival compared to the placebo. Overall survival and response rates were also improved with sunitinib treatment.
Management of oncology emergencies, Mohh'd sharshirMoh'd sharshir
This document summarizes the management of oncologic emergencies, focusing on tumor lysis syndrome (TLS). TLS is caused by massive lysis of tumor cells, releasing potassium, phosphate and uric acid. It is classified based on laboratory and clinical criteria. Risk is highest in Burkitt lymphoma, ALL and other high-grade lymphomas. Prevention focuses on IV hydration and hypouricemic agents like rasburicase or allopurinol. Electrolyte abnormalities are managed based on their severity. High-risk patients receive aggressive prevention while intermediate-risk patients generally receive allopurinol prevention.
Early goal-directed therapy in severe sepsis and septic shock: ProCESS, ARISE...Moh'd sharshir
1) This study compared early goal-directed therapy (EGDT) to usual care in patients with septic shock. EGDT aimed to optimize tissue oxygen delivery through monitoring of physiological targets like central venous pressure and central venous oxygen saturation.
2) The study found no significant difference in 90-day mortality between the EGDT and usual care groups. Patients in the EGDT group received more intravenous fluids and vasopressors but this did not impact mortality outcomes.
3) The study concludes that EGDT did not decrease mortality in patients presenting with septic shock compared to usual resuscitation practices. The value of incorporating EGDT into international guidelines is questionable.
Bathing of critically ill patients with chlorhexidine decreases hospital acqu...Moh'd sharshir
This meta-analysis examined the effect of daily bathing with chlorhexidine on hospital-acquired bloodstream infections in critically ill patients. The analysis found that daily chlorhexidine bathing reduced the risk of hospital-acquired bloodstream infections by 18% and was most effective at reducing gram-positive infections and catheter-related bloodstream infections when used with intranasal mupirocin. However, chlorhexidine bathing did not significantly impact gram-negative bacteria or fungal infections. The analysis concluded that chlorhexidine bathing may be an effective strategy to reduce healthcare-associated infections when combined with other preventative measures.
Case presentation, meningitis and treatment, Moh'd SharshirMoh'd sharshir
Meningitis is an inflammation of the meninges, the membranes surrounding the brain and spinal cord. It is caused by bacterial, viral, or fungal infections. The classic symptoms are fever, headache, and neck stiffness. Diagnosis involves examination of cerebrospinal fluid which shows increased white blood cells and decreased glucose levels in bacterial meningitis. Treatment depends on the identified pathogen but generally involves antibiotics. Adjunctive steroids may reduce complications for some types of bacterial meningitis. Outcomes vary depending on the cause, but bacterial meningitis can have mortality rates around 20% even with treatment.
Aortic dissection, pathophysiology, risk, incidence, types and treatment, Moh...Moh'd sharshir
This document presents a case of a 55-year-old man with a history of diabetes, hypertension, and prior stroke who was transferred for endovascular aortic repair after a motor vehicle accident caused multiple injuries including head trauma, chest trauma, cardiac contusion, aortic injury, and bone fractures. On examination, he was intubated and sedated. Imaging showed aortic pseudoaneurysm, lung effusions, and subcutaneous emphysema. The document then reviews aortic dissection including types, risk factors, clinical manifestations, diagnosis, and involvement of the ascending versus descending aorta.
This document summarizes adjuvant chemotherapy for resectable non-small cell lung cancer (NSCLC). It discusses that patients with stage I-IIIA NSCLC have a risk of recurrence even after surgery. Large clinical trials have found that platinum-based adjuvant chemotherapy can improve outcomes for completely resected NSCLC. Specifically, the IALT trial found that cisplatin-based chemotherapy improved 5-year survival from 40.4% to 44.5% compared to observation alone. The JBR.10 trial found that vinorelbine and cisplatin improved 5-year survival from 54% to 69% compared to observation. The CALGB 9633 trial initially found paclitaxel/carboplatin improved outcomes but
A Randomized Trial of Vitamin D Supplementation on Vascular Function in CKD, ...Moh'd sharshir
Vitamin D deficiency is common in CKD patients and linked to increased cardiovascular disease risk. This study found that cholecalciferol supplementation in nondiabetic CKD patients with vitamin D deficiency significantly improved brachial artery flow-mediated dilation and pulse wave velocity, markers of endothelial function and arterial stiffness respectively, over 16 weeks. Biomarkers of endothelial function, inflammation, and vascular calcification also improved. These results provide evidence that correcting vitamin D deficiency reduces cardiovascular risk in CKD patients.
kidney disease in HIV-positive patients, Moh'd sharshirMoh'd sharshir
Patients with HIV are at risk for both acute kidney injury and chronic kidney disease due to various factors like medication toxicity, HIV-associated nephropathy, and immune complex kidney diseases. The risk factors for acute kidney injury in HIV patients are similar to the general population but also include factors specific to HIV like low CD4 count and co-infection with hepatitis C virus. Timely screening for chronic kidney disease is important in HIV patients to monitor for decline in kidney function and proteinuria, in order to guide management and reduce risk of end-stage renal disease.
Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes, Moh'd sharshirMoh'd sharshir
This document summarizes the LEADER clinical trial which assessed the long-term cardiovascular safety of the diabetes drug liraglutide. The trial involved over 9,000 patients with type 2 diabetes at high risk of cardiovascular disease who were randomly assigned to receive either liraglutide or a placebo over a follow-up period of 3-5 years. The primary outcome was a composite of death from cardiovascular causes, non-fatal heart attack or non-fatal stroke. The results showed that liraglutide was associated with a lower rate of the primary composite outcome compared to placebo.
Therapy of focal or diffuse proliferative lupus nephritis, Moh'd sharshirMoh'd sharshir
Immunosuppressive therapy is recommended for patients with diffuse or focal proliferative lupus nephritis (LN). The standard induction therapies are cyclophosphamide or mycophenolate mofetil combined with glucocorticoids. Mycophenolate mofetil may be preferred in certain groups due to its comparable efficacy and better safety profile. Rituximab combined with mycophenolate mofetil and glucocorticoids has also shown efficacy in treating proliferative LN. Calcineurin inhibitors and other novel agents are being studied but cyclophosphamide and mycophenolate mofetil remain the standard of care.
This document discusses various treatment strategies for diabetic nephropathy, including ACE inhibitors, ARBs, glycemic control, SGLT2 inhibitors, and GLP-1 receptor agonists. It provides evidence from clinical trials that ACE inhibitors and ARBs reduce kidney disease progression in both type 1 and type 2 diabetes. Intensive glycemic control with medications or pancreas transplant can slow kidney disease, though the evidence is less clear for type 2 diabetes. Newer drugs like SGLT2 inhibitors and GLP-1 agonists may provide renoprotection based on trial results showing reduced albuminuria, kidney function decline, and cardiovascular outcomes.
Multitarget Therapy for InductionTreatment of Lupus Nephritis, Moh'd sharshirMoh'd sharshir
This study compared the efficacy and safety of a multitarget regimen consisting of tacrolimus, mycophenolate mofetil (MMF), and steroids to intravenous cyclophosphamide (IVCY) and steroids as induction therapy for lupus nephritis (LN). 368 patients with LN were randomly assigned to receive either the multitarget regimen or IVCY. The multitarget regimen resulted in significantly higher rates of complete remission and overall response. Adverse events were similar between groups. The multitarget regimen was found to be superior to IVCY as induction therapy for LN.
Novel oral anticoagulants in CKD review, Moh'd sharshirMoh'd sharshir
This document discusses the use of novel oral anticoagulants (NOACs) for stroke prevention and venous thromboembolism in patients with chronic kidney disease (CKD). It reviews recent trials that have re-analyzed data focusing on patients with reduced kidney function. Network meta-analyses found that NOACs were associated with lower risks of stroke, systemic embolism, and major bleeding compared to warfarin in CKD patients. Observational studies also suggest NOACs like apixaban, rivaroxaban, and dabigatran are similar or superior alternatives to warfarin for safety and efficacy in real-world CKD populations. However, more research is still needed, as
Delayed Graft Function post kidney transplant, Moh'd sharshirMoh'd sharshir
Induction therapy with anti-thymocyte globulin (ATG) may decrease the risk of delayed graft function (DGF) in deceased donor kidney transplant recipients by ameliorating ischemia reperfusion injury. A retrospective study of 76 mated kidney transplants found a non-significant 35% decrease in the odds of DGF when ATG was used compared to basiliximab. Larger prospective studies are still needed to confirm ATG's potential protective effect against DGF.
Donor-derived cell-free DNA (dd-cfDNA) is a potential noninvasive biomarker for detecting kidney transplant rejection. This study evaluated dd-cfDNA levels in 384 kidney transplant patients. Dd-cfDNA levels were significantly higher in patients with active rejection compared to those without rejection. Dd-cfDNA discriminated active rejection with 85% specificity and 59% sensitivity. Dd-cfDNA also strongly discriminated antibody-mediated rejection from no rejection, with 83% specificity and 81% sensitivity. In contrast, serum creatinine did not provide any discrimination of rejection status. This study suggests dd-cfDNA may enable noninvasive detection and monitoring of kidney transplant rejection.
Nephrogenic systemic fibrosis (NSF) is a severe skin condition seen in patients with kidney failure exposed to gadolinium-based contrast agents. The document discusses the clinical features and pathogenesis of NSF and provides recommendations to minimize the risk of NSF in patients with kidney disease requiring gadolinium imaging. It is recommended that gadolinium be avoided in patients with eGFR <30 mL/min or on dialysis unless absolutely necessary. For patients who must receive gadolinium, a macrocyclic agent at the lowest possible dose is preferred, and hemodialysis should be performed within hours after administration.
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Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
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We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
2. Introduction:
■ The prevalence of CKD in women of childbearing age ranges from 0.1% to 3%.
■ Furthermore, pregnancy is generally considered to be a risk factor for the
progression of CKD.
3. Introduction:
■ Previous systematic reviews indicated that the risk of adverse maternal and fetal
outcomes was higher in patients with CKD compared with those without CKD, but
the influence of pregnancy on renal outcomes was undetermined.
Piccoli GB, Conijn A, AttiniR, Biolcati M, Bossotti C, Consiglio V, Deagostini MC, Todros T: Pregnancy in chronic kidney disease: Need for a common language. J Nephrol 24: 282–299, 2011
4. Introduction:
■ Traditionally, it was considered that CKD progressively worsens in pregnant
women, especially with serious pathologic changes or renal insufficiency
before pregnancy (42–44).
■ Therefore, women with CKD were usually advised to avoid gestation,
except for recipients of renal transplants with stable renal function.
5. Introduction:
■ Here, they conducted a systematic review and meta-analysis of published cohort
studies and case control studies to obtain an overall estimate of the potential effect
of CKD and pregnancy on each other.
6. Materials and Methods:
■ They conducted and reported this
systematic review according to published
guidelines, using a prespecified protocol.
Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group: Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. J Clin Epidemiol 62: 1006–1012, 2009
7. Eligibility Criteria:
■ They included cohort studies and case-control studies that reported maternal or
fetal outcomes in pregnant women with CKD and without CKD as a comparator
group who may or may not have had other comorbidities (e.g., diabetes mellitus) or
studies that reported renal outcomes in pregnant women with CKD and
nonpregnant women with CKD as a comparator group.
8. Eligibility Criteria:
■ Primary studies defined CKD as any of the following: abnormal serum creatinine
(SCr)/abnormal GFR and/or proteinuria with a specific primary or secondary kidney
disease.
■ CKD is classified into five stages.
■ Adverse maternal outcomes were defined by the primary study authors and
included preeclampsia, eclampsia, and maternal mortality.
■ Adverse fetal outcomes included premature births, small for gestational age (SGA),
low birth weight, neonatal mortality, and stillbirths.
■ Renal outcomes included incidence of ESRD requiring RRT, doubling of SCr, and
50% decrement of eGFR/creatinine clearance rate (CCr).
9. Eligibility Criteria:
■ They excluded studies of women with a history of autoimmune diseases
(SLE, ANCA-associated systemic vasculitis, or Sjögren syndrome),
hereditary kidney disease, kidney transplant, or maintenance dialysis, as
well as studies of women with AKI or a single kidney.
10. Search Strategy:
■ They searched the following electronic databases from the date of inception up to
November 2014: MEDLINE (Ovid, 1946–2014) and Embase (1988–2014).
11. Study Selection:
■ Full-text articles considered potentially relevant were retrieved.
■ To ensure accuracy, the articles were independently screened the full-text articles
for inclusion.
■ Disagreement over eligibility was resolved by discussion or with the help of another
reviewer.
12. Study Quality:
■ The evidential level of each outcome of the studies was determined in accordance
with the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) system and was conducted with GRADE profiler 3.6.
■ Publication bias was assessed by creating and examining funnel plots.
■ A sensitivity analysis was performed by omitting studies with the smallest number of
participants and investigating the influence on the overall meta-analysis estimate.
13. Statistical Analyses:
■ The data was independently abstracted in duplicate to increase accuracy and
reduce measurement bias.
■ Disagreements were resolved with the help of another reviewer.
14. Statistical Analyses:
■ The following data were extracted: title, author, year, journal, period of study,
country, type of study, number of cases, number of pregnancies, mean age, type of
study population, preeclampsia, gestational age, birth weight, preterm delivery,
cesarean section, other maternal complications, stillbirth/neonatal death, SGA,
other neonatal complications, the number of adverse renal outcome events,
baseline and follow-up BP, proteinuria, eGFR, and SCr.
15. Statistical Analyses:
■ They also calculated stillbirth, fetal death, and neonatal death together as
pregnancy failure because these outcomes were so serious that they led to failure
of pregnancy.
16. Statistical Analyses:
■ Summary estimates of the odds ratio (ORs) and 95% confidence intervals (95%
CIs) or mean difference and 95% CIs for continuous variables were obtained using
a random-effects model.
■ Heterogeneity across the included studies was analyzed using the I2 statistic.
■ They performed additional subgroup analyses by pooling estimates for subgroups
defined by the median, and the level of adjustment when these were reported.
17. Statistical Analyses:
■ The definition of macroproteinuria was PCR > 500 mg/g or urinary albumin-to-
creatinine ratio > 300 mg/g according to the Kidney Disease Improving Global
Outcomes 2012 CKD guideline, and the definition of microproteinuria was the level
of proteinuria below macroproteinuria.
■ All analyses were performed using Stata (release 11.0) or RevMan (release 5.2)
software.
■ A standard level (P< 0.05) of statistical significance was used in all analyses.
19. Study Selection and General Information:
■ They screened and evaluated 6372 citations, of which 143 were reviewed in full text.
■ Twenty-two were selected as relevant studies for our analysis, and one study that
was published as an American Society of Nephrology 2014 meeting abstract was
also added.
20. Study Selection and General Information:
■ Among 23 retrieved studies, 12 were prospective studies, 7 were retrospective
studies, and 4 did not mention whether they were retrospective or prospective.
■ Twelve studies were from European countries, five were from the United States,
four were from Asia, and two were from Brazil.
■ This meta-analysis of 23 selected studies including 504,826 pregnancies and 1514
pregnancies with CKD investigated the associations between pregnancy and CKD
outcomes as well as CKD and fetal/maternal outcomes during pregnancy.
■ Of the 23 studies (n=505,759 pregnancies), 14 of the reported adverse maternal or
fetal outcomes in pregnant women with CKD.
21. Study Selection and General Information:
■ The definition of CKD varied across the studies:
Among 14 studies, 8 enrolled patients diagnosed with diabetic nephropathy (DN)
with proteinuria, 3 defined CKD according to the National Kidney Foundation Kidney
Disease Outcomes Quality Initiative definition, 1 defined CKD according to by
medical coding , and 1 defined CKD by biopsy.
One study enrolled pregnant women with low kidney function defined as SCr >/=1.5
mg/dl.
22.
23. Study Selection and General Information:
■ Six studies compared the maternal or fetal outcomes in pregnant women with CKD
with healthy pregnant women.
■ The remaining eight studies involving patients with DN had a control group with
comorbidities of diabetes with normal proteinuria and kidney function.
■ Four of 14 studies accounted for potential confounding factors such as proteinuria,
hypertension, systolic BP, and so forth (Tables 1 and 2).
24.
25.
26. Study Selection and General Information:
■ Of the 23 studies, 9 (n=1342) described the renal outcomes of pregnant women with CKD.
■ Mean follow-up was 8.6 years (range, 3–18 years) and median follow-up was 5 years
(interquartile range, 5–14.7 years).
■ Five studies enrolled pregnant women with IgA nephropathy, one study dealt with DN, and
three studies analyzed primary GN with various diagnoses.
■ The patients in the control groups were all nonpregnant women with matched age, type of
disease, and renal function.
■ Six of nine studies accounted for confounding factors such as proteinuria, mean arterial
pressure, eGFR, and so forth (Tables 3 and 4).
27.
28.
29. Effect of the Kidney Disease on Pregnancy:
■ Pregnancy outcomes in kidney disease varied among the studies.
■ They analyzed preeclampsia, premature birth, SGA/ low birth weight, cesarean
section, and failure of pregnancy (including stillbirth, fetal death, and neonatal
death) in pregnancies with CKD, according to former studies.
30. Effect of the Kidney Disease on Pregnancy:
■ Nine studies evaluated the occurrence of preeclampsia.
■ Overall, there were 14,993 events in 504,700 pregnancies.
■ The overall preeclampsia OR was 10.36 (95% CI, 6.28 to 17.09; P< 0.01; Figure 2)
in women with CKD compared with women without CKD.
31. Figure 2. | Overall odds ratios of the association of CKD and preeclampsia. 95% CI,
95% confidence interval.
32. Effect of the Kidney Disease on Pregnancy:
■ Ten studies reported 25,273 failures of pregnancy among 505,038 pregnancies.
■ Compared with the controls, patients with CKD with pregnancy had a significantly
higher rate of pregnancy failure (OR, 1.80; 95% CI, 1.03 to 3.13; P=0.04; Figure
3).
33. Figure 3. | Overall odds ratios of the association of CKD and failure of pregnancy (including stillbirth, fetal
death, and neonatal death). 95% CI, 95% confidence interval.
34. Effect of the Kidney Disease on Pregnancy:
■ The odds of premature birth, cesarean section, and SGA/low birth weight were also
higher in women with CKD, with ORs of 5.72 (95% CI, 3.26 to 10.03)
(Supplemental Figure 1), 4.85 (95% CI, 3.03 to 7.76) (Supplemental Figure 2),
and 2.67 (95% CI, 2.01 to 3.54) (Supplemental Figure 3).
35. Supplementary figure 1 Overall odds ratio (OR) of the association of CKD and
premature delivery.
36. Supplementary figure 2 Overall odds ratio (OR) of the association of CKD and small for
gestational age/low birth weight.
37. Supplementary figure 3 Overall odds ratio (OR) of the association of CKD and
cesarean section.
38. Effect of the Kidney Disease on Pregnancy:
■ Subgroup analysis showed that odds of preeclampsia (P=0.002), and premature
birth (P< 0.01) were higher in women with nondiabetic nephropathy than those
with DN (Figure 4).
■ The odds of preeclampsia (P=0.01) and premature delivery (P< 0.01) were higher
in women with macroproteinuria compared with those with microproteinuria
(Figure 4).
■ The identified between-study heterogeneity in failure of pregnancy (P=0.03) was
also caused by differences in sample size (Figure 4).
39. Figure 4. |
• Odds ratios of CKD on pregnancy complications
according to subgroups of publication year, sample size,
type of study population, and proteinuria.
• Microproteinuria indicates albuminuria 30–300 mg/24 h
or total proteinuria 150–500 mg/24 h, whereas
macroproteinuria indicates albuminuria >/=300 mg/24 h
or total proteinuria >/= 500 mg/24 h. 95% CI, 95%
confidence interval; DN, diabetic nephropathy; SGA,
small for gestational age.
40. Effect of the Kidney Disease on Pregnancy:
■ Most studies did not provide the full baseline data, such as BP, eGFR/CCr, and
SCr, which did not allow us to analyze whether these factors affected the
heterogeneity of pregnancy outcomes.
41. Effect of Pregnancy on Kidney Disease:
■ Eight studies reported 216 renal outcomes in 1268 participants.
■ Renal outcomes were defined as doubling of SCr levels, 50% decrement of
eGFR/CCr, or ESRD.
■ Compared with the control group, there was no difference in renal outcomes of
pregnant women with CKD (OR, 0.96; 95% CI, 0.69 to 1.35; P=0.83) (Figure 5).
42. Figure 5. | Overall odds ratios of the association of pregnancy and renal events (including doubling
of serum creatinine levels, 50% decrement of eGFR/CCr, and ESRD). 95% CI, 95% confidence
interval; CCr, creatinine clearance rate.
43. Effect of Pregnancy on Kidney Disease:
■ Only part of one study enrolled pregnant women with low kidney function (SCr
>1.2 mg/dl) before pregnancy.
■ There was also no significant difference in renal outcomes compared with the
control group (OR, 0.93; 95% CI, 0.17 to 5.15; Figure 5).
Rossing K, Jacobsen P, Hommel E, Mathiesen E, Svenningsen A, Rossing P, Parving HH: Pregnancy and progression of diabetic nephropathy. Diabetologia 45: 36–41, 20
44. Figure 5. | Overall odds ratios of the association of pregnancy and renal events (including doubling
of serum creatinine levels, 50% decrement of eGFR/CCr, and ESRD). 95% CI, 95% confidence
interval; CCr, creatinine clearance rate.
45. Effect of Pregnancy on Kidney Disease:
■ Subgroup analysis indicated that there was no significant difference according to
type of participants, CKD stage, baseline systolic BP, baseline proteinuria, and
level of SCr, publication year, sample size, and follow-up year (Figure 6).
46. Figure 6. | Odds ratios of pregnancy on renal out comes
according to subgroups of sample size, publication year,
follow-up year, type of study population, CKD classification,
baseline serum creatinine, baseline systolic BP, and baseline
proteinuria. 95% CI, 95% confidence interval; A, albuminuria
(mg/24 h); DN, diabetic nephropathy; SBP, systolic BP; SCr,
serum creatinine; T, total proteinuria (g/24 h).
47. Effect of Pregnancy on Kidney Disease:
■ Four studies reported the eGFR/CCr at the end of follow-up point (452
participants).
■ There was no significant difference in eGFR/CCr at the end of studies between
pregnant groups and nonpregnant groups (mean difference 2.91 ml/min; 95% CI,
22.42 to 8.24; P=0.28; Figure 7).
48. Figure 7. | Outcome of eGFR/CCr in women with CKD after pregnancy compared with non-pregnancy. 95% CI, 95%
confidence interval; CCr, creatinine clearance rate. IV, method of analysis was inverse variance.
49. Risk of Bias within Studies:
■ The GRADE evaluation indicated that the outcomes of preeclampsia and
premature delivery had high-quality evidence.
■ However, the quality of the evidence on SGA/ low birth weight was low, and failure
of pregnancy, cesarean section, and renal events were very low
50. Discussion:
■ The key finding of the systematic review of 216 renal events in 1268 participants
was that there was no significant difference in renal outcomes in pregnant women
compared with nonpregnant women who had CKD.
■ This association was uniformly consistent across subgroups characterized by
type of kidney disease, grade of CKD, systolic BP, and urinary proteins, which are
traditionally considered important risk factors for the decline of renal function.
in this meta-analysis, there was no significant difference in renal outcomes between
pregnant women with stage 1–3 CKD and those without pregnancy.
51. Discussion:
■ They also observed that adverse pregnancy events, including preeclampsia,
premature birth, SGA/low birth weight, and cesarean section, were remarkably
higher in women with CKD than in women without CKD.
■ In particular, risks of failure of pregnancy, including stillbirth, fetal death, and
neonatal death were higher in pregnant women with CKD.
52. Discussion:
■ The odds of adverse pregnancy outcomes were different for various renal
diseases.
The odds of premature delivery and preeclampsia were significantly higher in
women with nondiabetic nephropathy compared with those with DN.
53. Discussion:
■ They found that the odds of preeclampsia and premature delivery were higher in
women with macroproteinuria compared with women with microproteinuria.
54. Discussion:
■ Higher rates of successful pregnancy outcomes in women with DN have been
reported with treatment with angiotensin-converting enzyme inhibitors combined
with strict metabolic control for at least 6 months before gestation (42).
■ Therefore, measuring proteinuria is important before or early in pregnancy,
because proteinuria could predict patients at high risk for complications (43).
55. Discussion/ strengths :
■ This review had a number of strengths:
They compared not only maternal and fetal outcomes between women with and
without CKD but also CKD progression in women with CKD who did or did not
become pregnant.
56. Discussion/ limitations :
■ There were several limitations in this meta-analysis:
First, the data recorded in our study were not robust, because most related studies
were performed in a single center with limited numbers of participants and overall
low methodologic quality.
Second, there was insufficient data to assess the degree of risk at various levels of
albuminuria and SCr/ eGFR on adverse pregnant outcomes.
Third, there were only a few studies that assessed the association between renal
pathology and pregnancy outcome.
Finally, we could not evaluate the effect of pregnancy on patients with stage 4 CKD
because of a lack of relevant studies.
58. The risks of adverse maternal and fetal outcomes in pregnancy are
higher for women with CKD versus pregnant women without CKD.
However, pregnancy was not a risk factor for progression of renal
disease in women with CKD before pregnancy.
Editor's Notes
However, One possible reason was that women with serious renal insufficiency were unable to experience gestation.
In addition, many pregnant women may have chosen to terminate gestation when their renal disease began to deteriorate.
The termination of pregnancy would stop or reverse the progression of renal disease, which would make it possible for renal outcomes in such pregnant women to become comparable with nonpregnant women with CKD.
However, because most of the studies examining CKD outcomes among pregnant women included patients with IgA nephropathy, these results may not be extrapolated to groups of patients with other underlying causes of renal disease.
One reason for the difference might be the different stage of renal function, The definition of DN in the studies retrieved was the detection of proteinuria, and renal function was in the normal range.
However, renal function in two studies with nondiabetic nephropathy was insufficient.
This indicated that renal function status might influence the pregnancy outcomes in patients with CKD.
Some studies indicated that pregnant women with low kidney function delivered preterm because of complications, including worsening renal function, increasing BP, and anemia.
Therefore, renal insufficiency might have an effect on the risk of premature delivery and preeclampsia.
Some pregnant women with CKD in the studies retrieved in our meta-analysis had normal renal function, and the definition of CKD was more likely according to albuminuria.
However, inhibitors of the renin angiotensin system should not be continued once pregnancy is either planned or detected because of serious risk of fetal malformations.
Another systematic review produced bias in selection on account of excluding IgA nephropathy, which is the most common primary GN.
Furthermore, our review did not analyze the subgroup data for important risk factors for renal events (including heavy proteinuria > 3g/d or hypertension) because there were no individual patient data.