Sunday, September 21, 2014

Is this the best review on treating hypertension in pregnancy? Updated

Note: this is a living post that is growing as I brush up on preeclampsia

From Hypertension:

Update on the Use of Antihypertensive Drugs in Pregnancy


Another great article:

New aspects of pre-eclampsia: lessons for the nephrologist

Also with a free PDF. Thanks NDT.

Although these renal changes in general are believed to resolve completely after delivery, recent evidence suggests that pre-eclampsia may leave a permanent renal damage.
CKD is a risk factor for pre-eclampsia in advanced CKD 3-5, weak evidence
the risk for pre-eclampsia and other pregnancy complications is sub-stantially increased in women with chronic kidney disease (CKD) stages 3–5 
 CKD 1-3 is not a risk factor unless the woman also has hypertension, higher quality evidence.
but these women were not at increased risk for pre-eclampsia. However, there was a significant biological interaction between eGFR and hypertension making eGFR 60–89 ml/min per 1.73 m2 a risk factor for pre-eclampsia if the women were also hypertensive.
Pre-eclampsia increases the risk for subsequent kidney biopsy and subsequent ESRD:
In the first study, women with pre-eclampsia in their first pregnancy had a considerably increased risk of developing kidney disease that needed investigation with a kidney biopsy [Adverse Perinatal Outcome and Later Kidney Biopsy in the Mother in JASN]. 
women who previously had pre-eclampsia had a four to five times increased risk of later end-stage renal disease, independent of primary renal disease [Preeclampsia and the Risk of End-Stage Renal Disease in NEJM]. Women with recurrent pre-eclamptic preg- nancies and women who gave birth to offspring with low birth weight had an even higher risk. The increased risk remained significant throughout the follow-up period of nearly 40 years. 

 In regards to the natural history of pre-eclampsia:
It should also be kept in mind that although the extensive glomerular changes during pre-eclampsia are believed to completely resolve after pregnancy [The Glomerular Injury of Preeclampsia in JASN], no studies have routinely performed a kidney biopsy months after the pre-eclamptic pregnancy. The fact that as many as 20–40% have microalbuminuria after a pre-eclamptic pregnancy may argue for a permanent glomerular damage in a great proportion of these women [Microalbuminuria after pregnancy complicated by pre-eclampsia in NDT, Blood pressure and renal function seven years after pregnancy complicated by hypertension].
Warning about these conclusions regarding pre-eclampsia causing CKD:
When interpreting the studies of pre-eclampsia and later kidney disease, it should be remembered that pre-eclampsia might unmask asymptomatic or undiagnosed CKD, a disease that might have been present also before pregnancy. A pre-pregnancy eGFR >60 ml/min per 1.73 m2 measured at screening was in a population-based sample associated with future pre-eclampsia risk in hypertensive women [Kidney function and future risk for adverse pregnancy outcomes in NDT]

This article by Eiland, Nzerue, and Faulkner in PubMed Central does a nice job reviewing the pathogenesis of the preeclampsia.

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