15th July 2024

Diagnosis and Management

In pregnancy, the following medications can safely continue:

• Tacrolimus
• Hydroxychloroquine
• Azathioprine
• Metformin
• Antihypertensives: Labetalol, Nifedipine, Methyldopa
• Erythropoietin analogues, e.g. Neorecormon and Aranesp (requirement increases in pregnancy)
• Activated vitamin D e.g. Alfacalcidol
• Steroids

Women taking calcineurin inhibitors or steroids during pregnancy should be screened for gestational diabetes.

Prior to pregnancy, administration of the following medications should be discontinued:

• Cyclophosphamide – stop 3 months prior to conception
• Methotrexate – stop six months prior to pregnancy
• Mycophenolate mofetil – stop 3 months prior to conception
• Rituximab – advise to avoid conception for 1 year after treatment (guidance may change)
• ACE inhibitors – can continue until conception
• Angiotensin receptor blockers – should discontinue prior to pregnancy
• Avoid sirolimus/everolimus
• Non-calcium-based phosphate binders
• Cinacalcet
• Diuretics should not be used to treat hypertension in pregnancy but can be used for symptomatic fluid overload

Contraception after cessation of medication before the safe time for conception; this time is known as the “washout period”. For women with CKD, oestrogen-containing contraceptives are usually contraindicated as they lead to increased risks of hypertension, as well as thromboembolism (especially for women with antiphospholipid syndrome or the nephrotic syndrome) and cervical malignancy (especially for women on immunosuppression). Progesterone based systems e.g. the Mirena coil and progesterone-only pill are acceptable. The copper intrauterine device can also be used.

If breastfeeding, the following medications can still be administered:

• Steroids
• Azathioprine
• Hydroxychloroquine
• Tacrolimus
• Everolimus

Renal conditions, such as glomerulonephritides, can present de novo in pregnancy. These can present very similarly to pre-eclampsia, with new proteinuria and renal impairment. However, pre-eclampsia does not lead to haematuria or the presence of red cell casts in the urine. Renal biopsy can be performed antenatally, although between 23-28/40 weeks, there is the highest risk of complications. After 28 weeks, most common presentations are haematomas and loin pain post procedure. A new presentation of nephrotic syndrome or acute glomerulonephritis may warrant a renal biopsy, although this must be balanced against the risks of biopsy and whether it will change treatment.

Increasingly, it is recognised that despite impaired fertility, women with end stage renal disease (ESRD) can become pregnant, although the rate of perinatal death is 50% for women established on dialysis, and 25% for those who start dialysis while pregnant. Women aiming to conceive should change from peritoneal dialysis (PD) to haemodialysis (HD) during pregnancy, as this reduces the risk of prematurity.

For women with progressive renal dysfunction, dialysis, i.e. haemodialysis, should be initiated with a urea level of 17 mmol/L or above, as urea is foeto-toxic. A target urea below 12 mmol/L should be aimed for. This usually requires more intensive dialysis. For anuric women on dialysis (i.e. those with no residual renal function), the target should be 36 hours of dialysis a week (usual dialysis regimens are 9-12 hours). This intense dialysis can lead to hypophosphataemia in the mother, which increases the risk of cervical shortening, and therefore, this must be replaced on dialysis.

Women with renal transplants should wait 1-year post transplant before conceiving. Women with SLE should be at least 6 months into remission on stable treatment before conceiving.