Kidney Week

Abstract: TH-PO628

Normal GFR to ESRD after Pregnancy with Diabetic Nephropathy

Session Information

• Fellows/Residents Case Reports: Genetic Diseases, Pregnancy, Monoclonal Gammopathy
  November 02, 2017 | Location: Hall H, Morial Convention Center
  Abstract Time: 10:00 AM - 10:00 AM

Category: Nephrology Education

• 1302 Fellows and Residents Case Reports

Authors

• Attique, Hassan Bin, University of Connecticut Health Center, Farmington, Connecticut, United States

Hassan Bin Attique,

• Lucas, Anika, University of Connecticut Health Center, Farmington, Connecticut, United States

Anika Lucas,

• Elali, Ibrahim, University of Connecticut Health Center, Farmington, Connecticut, United States

Ibrahim Elali,

Background

While pregnancy associated incidence of complications in Type 1 diabetic (T1D) patients with nephropathy is well established, the rate of progression of the nephropathy is yet to be adequately studied.

Methods

36 year old female with history of uncontrolled HTN and T1D, complicated with diabetic nephropathy, presented at 12 weeks of gestation with nephrotic range proteinuria of 7.6 g, creatinine clearance (Ccr) of 104 ml/min on 24- hour urine collection and a serum creatinine (SCr) of 0.8mg/dl. Prior to her pregnancy, her baseline SCr was 0.61mg/dl with estimated glomerular filtration rate (eGFR) of 118 ml/min/1.73m², and reported urinalysis with 2⁺- 3⁺ proteinuria or sub-nephrotic range.
During pregnancy, diabetes remained uncontrolled despite intensive insulin regimen. Blood pressure ranged from 116-167 mmHg systolic and 68-101 mmHg diastolic. Peak SCr was 1.2 mg/dl and protein-creatinine ratio (PCR) of 17 g/g. She developed preeclampsia at 35 weeks of gestation resulting in preterm delivery of 2095 g newborn via caesarean section. Post-delivery SCr at one month was 1.1 mg/dl with eGFR of 60 ml/min/1.73m², and albumin-creatinine ratio of 9 g/g.
Over the course of eight months postpartum, renal function continued to decline, and progressed to ESRD, requiring chronic renal replacement therapy support. Peak SCr was 4.3 mg/dl, and 24-hour urine collection revealed Ccr of 12.4 ml/min with 20 grams proteinuria. Serological workup was negative. Renal biopsy was consistent with diabetic nephropathy and showed diffuse nodular global sclerosis.

Conclusion

Although preclampsia, caesarean section, and preterm delivery are known complications in diabetic nephropathy, nephrotic range proteinuria with preserved GFR progressing to ESRD post pregnancy is not well documented. Previous studies showed no increased risk of overt nephropathy or ESRD in women with preserved GFR at conception, and proteinuria generally returns to baseline postpartum. We observed an accelerated decline in renal function as well as worsening proteinuria leading to ESRD post partum, requiring chronic hemodialysis support. Pre-existing Proteinuria seems to be a stronger factor than preserved GFR pre-pregnancy in predicting future progression and disease outcome. Aggressive preconception counseling should be considered to avoid preventable fetal and maternal morbidity, including the possibility of disease progression to ESRD.