Review Article

Kidney Disease in Pregnancy (Women’s Health Series)

Authors: Geeta Gyamlani, MD, Stephen A. Geraci, MD


Kidney disease and pregnancy may exist in two general settings: acute kidney injury that develops during pregnancy, and chronic kidney disease that predates conception. In the first trimester of pregnancy, acute kidney injury is most often the result of hyperemesis gravidarum, ectopic pregnancy, or miscarriage. In the second and third trimesters, the common causes of acute kidney injury are severe preeclampsia, hemolysis-elevated liver enzymes–low platelets syndrome, acute fatty liver of pregnancy, and thrombotic microangiopathies, which may pose diagnostic challenges to the clinician. Cortical necrosis and obstructive uropathy are other conditions that may lead to acute kidney injury in these trimesters. Early recognition of these disorders is essential to timely treatment that can improve both maternal and fetal outcomes. In women with preexisting kidney disease, pregnancy-related outcomes depend upon the degree of renal impairment, the amount of proteinuria, and the severity of hypertension. Neonatal and maternal outcomes in pregnancies among renal transplant patients are generally good if the mother has normal baseline allograft function. Common renally active drugs and immunosuppressant medications must be prescribed, with special considerations in pregnant patients.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Krane NK. Acute renal failure in pregnancy. Arch Intern Med. 1988; 148: 2347–2357.
2. Selcuk NY, Tonbul HZ, San A, et al. Changes in frequency and etiology of acute renal failure in pregnancy (1980–1997). Ren Fail. 1998; 20: 513–517.
3. Prakash J. The kidney in pregnancy: a journey of three decades. Indian J Nephrol. 2012; 22: 159–167.
4. Rasmussen PE, Nielsen FR. Hydronephrosis during pregnancy: a literature survey. Eur J Obstet Gynecol Reprod Biol. 1988; 27: 249–259.
5. Danielson LA, Kercher LJ, Conrad KP. Impact of gender and endothelin on renal vasodilation and hyperfiltration induced by relaxin in conscious rats. Am J Physiol Regul Integr Comp Physiol. 2000; 279: R1298–R1304.
6. Conrad KP, Lindheimer M. Renal and cardiovascular alterations. in Lindheimer M, Roberts J, Cunningham F. (eds): Chesley’s Hypertensive Disorders in Pregnancy. Amsterdam: Elsevier, 2009;, ed 3, pp 297–334.
7. Jeyabalan A, Conrad KP. Renal function during normal pregnancy and preeclampsia. Front Biosci. 2007; 12: 2425–2437.
8. August P. The kidney in pregnancy. in Greenberg A, Cheung A, Falk R, et al. (eds): Primer on Kidney Diseases. Philadelphia: National Kidney Foundation, 2005;, ed 4, pp 426–435.
9. Wolfe LA, Kemp JG, Heenan AP, et al. Acid-base regulation and control of ventilation in human pregnancy. Can J Physiol Pharmacol. 1998; 76: 815–827.
10. Sánchez-Luceros A, Farías CE, Amaral MM, et al. von Willebrand factor-cleaving protease (ADAMTS13) activity in normal non-pregnant women, pregnant and post-delivery women. Thromb Haemost. 2004; 92: 1320–1326.
11. Mannucci PM, Canciani MT, Forza I, et al. Changes in health and disease of the metalloprotease that cleaves von Willebrand factor. Blood. 2001; 98: 2730–2735.
12. Baylis C, Davison JM. The urinary system. in Chamberlain G, Broughton-Pipkin F. (eds): Clinical Physiology in Obstetrics. Oxford: Blackwell Scientific, 1998;, ed 3, pp 263–307.
13. Stratta P, Besso L, Canavese C, et al. Is pregnancy-related acute renal failure a disappearing clinical entity? Ren Fail. 1996; 18: 575–584.
14. Goodwin TM. Hyperemesis gravidarum. Clin Obstet Gynecol. 1998; 41: 597–605.
15. Abell TL, Riely CA. Hyperemesis gravidarum. Gastroenterol Clin North Am. 1992; 21: 835–849.
16. Goodwin TM, Montoro M, Mestman JH, et al. The role of chorionic gonadotropin in transient hyperthyrodism of hyperemesis gravidarum. J Clin Endocrinol Metab. 1992; 75: 1333–1337.
17. Speert H, Guttmacher AF. Frequency and significance of bleeding in early pregnancy. JAMA. 1954; 155: 712–715.
18. Fakhouri F, Frémeaux-Bacchi V. Does hemolytic uremic syndrome differ from thrombotic thrombocytopenic purpura? Nat Clin Pract Nephrol. 2007; 3: 679–687.
19. Matthews JH, Benjamin S, Gill DS, et al. Pregnancy associated thrombocytopenia: definition, incidence and natural history. Acta Haematol. 1990; 84: 24–29.
20. Martin JN Jr, Bailey AP, Rehberg JF, et al. Thrombotic thrombocytopenic purpura in 166 pregnancies: 1955-2006. Am J Obstet Gynecol. 2008; 199: 98–104.
21. Furlan M, Robles R, Galbusera M, et al. von Willebrand factor-cleaving protease in thrombotic thrombocytopenic purpura and the hemolytic-uremic syndrome. N Engl J Med. 1998; 339: 1578–1584.
22. Levy GG, Nichols WC, Lian EC, et al. Mutations in a member of the ADAMTS gene family cause thrombotic thrombocytopenic purpura. Nature. 2001; 413: 488–494.
23. Tsai HM. Pathophysiology of thrombotic thrombocytopenic purpura. Int J Hematol. 2010; 91: 1–19.
24. George JN. Clinical practice. Thrombotic thrombocytopenic purpura. N Engl J Med. 2006; 354: 1927–1935.
25. Besbas N, Karpman D, Landau D, et al. European Paediatric Research Group for HUS. A classification of hemolytic uremic syndrome and thrombotic thrombocytopenic purpura and related disorders. Kidney Int. 2006; 70: 423–431.
26. Fakhouri F, Roumenina L, Provot F, et al. Pregnancy-associated hemolytic uremic syndrome revisited in the era of complement gene mutations. J Am Soc Nephrol. 2010; 21: 859–867.
27. Michael M, Elliott EJ, Ridley GF, et al. Interventions for hemolytic uraemic syndrome and thrombotic thrombocytopenic purpura. Cochrane Database Syst Rev. 2009; 1: CD003595
28. Gammill HS, Jeyabalan A. Acute renal failure in pregnancy. Crit Care Med. 2005; 33: S372–S384.
29. Dashe JS, Ramin SM, Cunningham FG. The long-term consequences of thrombotic microangiopathy (thrombotic thrombocytopenic purpura and hemolytic uremic syndrome) in pregnancy. Obstet Gynecol. 1998; 91: 662–668.
30. Lindheimer MD, Davison JM. Renal biopsy during pregnancy: ‘to b . . . or not to b.?.’. Br J Obstet Gynaecol. 1987; 94: 932–934.
31. Noris M, Remuzzi G. Atypical hemolytic-uremic syndrome. N Engl J Med. 2009; 361: 1676–1687.
32. ACOG Committee on Practice Bulletins-Obstetrics. ACOG practice bulletin. Diagnosis and management of preeclampsia and eclampsia. Number 33, January 2002. Obstet Gynecol. 2002; 99: 159–167.
33. Meekins JW, Pijnenborg R, Hanssens M, et al. A study of placental bed spiral arteries and trophoblast invasion in normal and severe pre-eclamptic pregnancies. Br J Obstet Gynaecol. 1994; 101: 669–674.
34. Makris A, Thornton C, Thompson J, et al. Uteroplacental ischemia results in proteinuric hypertension and elevated sFLT-1. Kidney Int. 2007; 71: 977–984.
35. Kuklina EV, Ayala C, Callaghan WM. Hypertensive disorders and severe obstetric morbidity in the United States. Obstet Gynecol. 2009; 113: 1299–1306.
36. Thangaratinam S, Ismail KM, Sharp S, et al. Accuracy of serum uric acid in predicting complications of pre-eclampsia: a systematic review. BJOG. 2006; 113: 369–378.
37. Haram K, Svendsen E, Abildgaard U. The HELLP syndrome: clinical issues and management: a review. BMC Pregnancy Childbirth. 2009; 9: 8
38. Sibai BM, Ramadan MK, Usta I, et al. Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). Am J Obstet Gynecol. 1993; 169: 1000–1006.
39. Young BC, Levine RJ, Karumanchi SA. Pathogenesis of preeclampsia. Annu Rev Pathol. 2010; 5: 173–192.
40. Sibai BM. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Obstet Gynecol. 2004; 103: 981–991.
41. Drakeley AJ, Le Roux PA, Anthony J, et al. Acute renal failure complicating severe preeclampsia requiring admission to an obstetric intensive care unit. Am J Obstet Gynecol. 2002; 186: 253–256.
42. Picinni P, Gallo G. Diagnosis and management of HELLP syndrome. in Ronco C, Bellomo R, Kellum J. (eds): Critical Care Nephrology. Philadelphia, Saunders, 2009;, ed 2, pp 337–340.
43. van Runnard Heimel PJ, Franx A, Schobben AF, et al. Corticosteroids, pregnancy, and HELLP syndrome: a review. Obstet Gynecol Surv. 2005; 60: 57–70.
44. Lamer P. Current controversies surrounding the use of repeated courses of antenatal steroids. Adv Neonatal Care. 2002; 2: 290–300.
45. Castro MA, Fassett MJ, Reynolds TB, et al. Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. Am J Obstet Gynecol. 1999; 181: 389–395.
46. Fesenmeier MF, Coppage KH, Lambers DS, et al. Acute fatty liver of pregnancy in 3 tertiary care centers. Am J Obstet Gynecol. 2005; 192: 1416–1419.
47. Ibdah JA, Bennett MJ, Rinaldo P, et al. A fetal fatty-acid oxidation disorder as a cause of liver disease in pregnant women. N Engl J Med. 1999; 340: 1723–1731.
48. Amon E, Allen SR, Petrie RH, et al. Acute fatty liver of pregnancy associated with preeclampsia: management of hepatic failure with postpartum liver transplantation. Am J Perinatol. 1991; 8: 278–279.
49. Prakash J, Srivastava A, Singh S, et al. Renal cortical necrosis in a live kidney donor. Indian J Nephrol. 2012; 22: 48–51.
50. Lauler DP, Shreiner GE. Bilateral renal cortical necrosis. Am J Med. 1958; 24: 519–529.
51. Grünfeld JP, Pertuiset N. Acute renal failure in pregnancy: 1987. Am J Kidney Dis. 1987; 9: 359–362.
52. Matlin RA, Gary NE. Acute cortical necrosis. Case report and review of the literature. Am J Med. 1974; 56: 110–118.
53. Ali A, Ali MA, Ali MU, et al. Hospital outcomes of obstetrical-related acute renal failure in a tertiary care teaching hospital. Ren Fail. 2011; 33: 285–290.
54. Brandes JC, Fritsche C. Obstructive acute renal failure by a gravid uterus: a case report and review. Am J Kidney Dis. 1991; 18: 398–401.
55. Courban D, Blank S, Harris MA, et al. Acute renal failure in the first trimester resulting from uterine leiomyomas. Am J Obstet Gynecol. 1997; 177: 472–473.
56. Scarpa RM, De Lisa A, Usai E. Diagnosis and treatment of ureteral calculi during pregnancy with rigid ureteroscopes. J Urol. 1996; 155: 875–877.
57. Fischer MJ. Chronic kidney disease and pregnancy: maternal and fetal outcomes. Adv Chronic Kidney Dis. 2007; 14: 132–145.
58. Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. N Engl J Med. 1996; 335: 226–232.
59. Stratta P, Canavese C, Quaglia M. Pregnancy in patients with kidney disease. J Nephrol. 2006; 19: 135–143.
60. Holley JL, Bernardini J, Quadri KH, et al. Pregnancy outcomes in a prospective matched control study of pregnancy and renal disease. Clin Nephrol. 1996; 45: 77–82.
61. Barcelo P, Lopez- Lillo J, Cabero L, et al. Successful pregnancy in primary glomerular disease. Kidney Int. 1986; 30: 914–919.
62. Rossing K, Jacobsen P, Hommel E, et al. Pregnancy and progression of diabetic nephropathy. Diabetologia. 2002; 45: 36–41.
63. Khoury JC, Miodovnik M, LeMasters G, et al. Pregnancy outcome and progression of diabetic nephropathy. What’s next? J Matern Fetal Neonatal Med. 2002; 11: 238–244.
64. Quan A. Fetopathy associated with exposure to angiotensin converting enzyme inhibitors and angiotensin receptor antagonists. Early Hum Dev. 2006; 82: 23–28.
65. Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med. 2006; 354: 2443–2451.
66. Magee LA, Cham C, Waterman EJ, et al. Hydralazine for treatment of severe hypertension in pregnancy: meta-analysis. BMJ. 2003; 327: 955–960.
67. American Academy of Pediatrics Committee on Drugs. The transfer of drugs and other chemicals into human milk. Pediatrics. 1994; 93: 137–150.
68. Rahman FZ, Rahman J, Al-Suleiman SA, et al. Pregnancy outcome in lupus nephropathy. Arch Gynecol Obstet. 2005; 271: 222–226.
69. Hou S. Pregnancy in chronic renal insufficiency and end-stage renal disease. Am J Kidney Dis. 1999; 33: 235–252.
70. Erkan D. The relation between antiphospholipid syndrome-related pregnancy morbidity and non-gravid vascular thrombosis: a review of the literature and management strategies. Curr Rheumatol Rep. 2002; 4: 379–386.
71. Clowse ME, Magder L, Witter F, et al. Hydroxychloroquine in lupus pregnancy. Arthritis Rheum. 2006; 54: 3640–3647.
72. Anderka MT, Lin AE, Abuelo DN, et al. Reviewing the evidence for mycophenolate mofetil as a new teratogen: case report and review of the literature. Am J Med Genet A. 2009; 149A: 1241–1248.
73. McKay D, Josephson M, et al. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Tissues and Transplantation. Am J Transplant. 2005; 5: 1592–1599.
74. Framarino dei Malatesta M, Rossi M, Rocca B, et al. Fertility following solid organ transplantation. Transplant Proc. 2007; 39: 2001–2004.
75. Armenti VT, Radomski JS, Moritz MJ, et al. National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. in Cecka JM, Terasaki PI. (eds): Clinical Transplants 2004. Los Angeles, UCLA Immunogenetics Center, 2004; , pp 103–114.
76. Blowey DL, Warady BA. Outcome of infants born to women with chronic kidney disease. Adv Chronic Kidney Dis. 2007; 14: 199–205.
77. Danesi R, Del Tacca M. Teratogenesis and immunosuppressive treatment. Transplant Proc. 2004; 36: 705–707.
78. Sato JL, De Oliveira L, Kirsztajn GM, et al. Chronic kidney disease in pregnancy requiring first-time dialysis. Int J Gynaecol Obstet. 2010; 111: 45–48.
79. Jefferys A, Wyburn K, Chow J, et al. Peritoneal dialysis in pregnancy: a case series. Nephrology (Carlton). 2008; 13: 380–383.
80. Haase M, Morgera S, Bamberg C, et al. A systematic approach to managing pregnant dialysis patients—the importance of an intensified haemodiafiltration protocol. Nephrol Dial Transplant. 2005; 20: 2537–2542.