Visual Abstract

Background and Objectives: Kidney disorders in pregnancy may be under-recognized and have variable impact on outcomes depending on diagnosis. Population-level data are limited, particularly for Australia, and comparison of impact of different kidney disorders on pregnancy has rarely been assessed. This study examined the prevalence and outcomes of varied kidney disorders using population-level perinatal data from a large cohort. Methods: Women with singleton pregnancies > 20 weeks’ gestation from the South Australian Pregnancy Outcomes Unit (1990–2012). Women with a kidney disorders diagnostic code were grouped into categories (immunological, cystic/genetic, urological, vesicoureteral reflux (VUR), pyelonephritis and “other”). Key pregnancy outcomes were assessed, with adjustment for demographic variables. Results: Kidney disorders were reported in 1,392 (0.3%) of 407,580 births. These pregnancies had increased risk of pregnancy-induced hypertension (OR 2.16, 95% CI 1.82–2.56), induction of labor (RRR vs. spontaneous birth 2.10, 95% CI 1.87–2.36), all Caesarean section (OR 1.31, 95% CI 1.17–1.47) as well as Caesarean section without labor (RRR 1.82, 95% CI 1.57–2.10), preterm birth (< 37 weeks; 2.76, 95% CI 2.40–3.18), low birth weight (< 2,500 g) infants (OR 2.43, 95% CI 2.07–2.84), and neonatal intensive care admission (OR 2.64, 95% CI 2.12–3.29). Diagnostic subgroups demonstrated differing patterns of adverse outcomes, enabling the development of a matrix of risk. Women with immunological renal conditions and VUR had greatest risk overall, and only women with immunological diseases had increased risk of small-for-gestational age < 10th centile (OR 2.36, 95% CI 1.26–4.42). Women with nonchronic urological conditions and pyelonephritis had increased risk of preterm birth, but not other adverse events. VUR conferred particularly increased risk of Caesarean section and induced labor. Conclusions: In a cohort of > 1,300 women with varied kidney disorders, increased adverse obstetric and perinatal events were observed, and the nature and magnitude of risk differed according to diagnosis. In particular, vesicoureteric reflux is not a benign condition in pregnancy. Women with nonchronic conditions still had increased risk of preterm birth. We confirm that women with kidney disorders warrant vigilant and tailored prepregnancy care and clinical care in pregnancy.

Fitzpatrick A, Mohammadi F, Jesudason S. Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby.
Int J Womens Health
. 2016 Jul; 8: 273–85.
Piccoli GB, Attini R, Vasario E, Conijn A, Biolcati M, D’Amico F, et al. Pregnancy and chronic kidney disease: a challenge in all CKD stages.
Clin J Am Soc Nephrol
. 2010 May; 5(5): 844–55.
Piccoli GB, Cabiddu G, Attini R, Vigotti FN, Maxia S, Lepori N, et al. Risk of adverse pregnancy outcomes in women with CKD.
J Am Soc Nephrol
. 2015 Aug; 26(8): 2011–22.
Imbasciati E, Gregorini G, Cabiddu G, Gammaro L, Ambroso G, Del Giudice A, et al. Pregnancy in CKD stages 3 to 5: fetal and maternal outcomes.
Am J Kidney Dis
. 2007 Jun; 49(6): 753–62.
Munkhaugen J, Lydersen S, Romundstad PR, Widerøe TE, Vikse BE, Hallan S. Kidney function and future risk for adverse pregnancy outcomes: a population-based study from HUNT II, Norway.
Nephrol Dial Transplant
. 2009 Dec; 24(12): 3744–50.
Hladunewich MA, Melamed N, Bramham K. Pregnancy across the spectrum of chronic kidney disease.
Kidney Int
. 2016 May; 89(5): 995–1007.
Mohammadi FA, Borg M, Gulyani A, McDonald SP, Jesudason S. Pregnancy outcomes and impact of pregnancy on graft function in women after kidney transplantation.
Clin Transplant
. 2017 Oct; 31(10):e13089.
Wyld ML, Clayton PA, Jesudason S, Chadban SJ, Alexander SI. Pregnancy outcomes for kidney transplant recipients.
Am J Transplant
. 2013 Dec; 13(12): 3173–82.
Jesudason S, Grace BS, McDonald SP. Pregnancy outcomes according to dialysis commencing before or after conception in women with ESRD.
Clin J Am Soc Nephrol
. 2014 Jan; 9(1): 143–9.
Kendrick J, Sharma S, Holmen J, Palit S, Nuccio E, Chonchol M. Kidney disease and maternal and fetal outcomes in pregnancy.
Am J Kidney Dis
. 2015 Jul; 66(1): 55–9.
Farkash E, Weintraub AY, Sergienko R, Wiznitzer A, Zlotnik A, Sheiner E. Acute antepartum pyelonephritis in pregnancy: a critical analysis of risk factors and outcomes.
Eur J Obstet Gynecol Reprod Biol
. 2012 May; 162(1): 24–7.
Wing DA, Fassett MJ, Getahun D. Acute pyelonephritis in pregnancy: an 18-year retrospective analysis.
Am J Obstet Gynecol
. 2014 Mar; 210(3): 219.e1–6.
Tangren JS, Powe CE, Ecker J, Bramham K, Ankers E, Karumanchi SA, et al. Metabolic and hypertensive complications of pregnancy in women with nephrolithiasis.
Clin J Am Soc Nephrol
. 2018 Apr; 13(4): 612–9.
Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Giannattasio M, et al. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy.
J Nephrol
. 2016 Jun; 29(3): 277–303.
Tong A, Jesudason S, Craig JC, Winkelmayer WC. Perspectives on pregnancy in women with chronic kidney disease: systematic review of qualitative studies.
Nephrol Dial Transplant
. 2015 Apr; 30(4): 652–61.
Tong A, Brown MA, Winkelmayer WC, Craig JC, Jesudason S. Perspectives on pregnancy in women with CKD: a semistructured interview study.
Am J Kidney Dis
. 2015 Dec; 66(6): 951–61.
South Australian Pregnancy Outcomes Unit.
Pregnancy outcome in South Australia 2013
. Adelaide, Australia: SA Health; 2015.
Dobbins TA, Sullivan EA, Roberts CL, Simpson JM. Australian national birthweight percentiles by sex and gestational age, 1998-2007.
Med J Aust
. 2012 Sep; 197(5): 291–4.
Australian Bureau of Statistics. Socio-economic indexes for areas [Accessed July 17, 2016.]. Available from:
Shahir AK, Briggs N, Katsoulis J, Levidiotis V. An observational outcomes study from 1966-2008, examining pregnancy and neonatal outcomes from dialysed women using data from the ANZDATA Registry.
Nephrology (Carlton)
. 2013 Apr; 18(4): 276–84.
Australian Bureau of Statistics. Australian Health Survey: biomedical results for chronic diseases, 2011-2012 [Accessed April 13, 2018]. Available from:
Odutayo A, Hladunewich M. Obstetric nephrology: renal hemodynamic and metabolic physiology in normal pregnancy.
Clin J Am Soc Nephrol
. 2012 Dec; 7(12): 2073–80.
Nevis IF, Reitsma A, Dominic A, McDonald S, Thabane L, Akl EA, et al. Pregnancy outcomes in women with chronic kidney disease: a systematic review.
Clin J Am Soc Nephrol
. 2011 Nov; 6(11): 2587–98.
Zhang JJ, Ma XX, Hao L, Liu LJ, Lv JC, Zhang H. A systematic review and meta-analysis of outcomes of pregnancy in CKD and CKD outcomes in pregnancy.
Clin J Am Soc Nephrol
. 2015 Nov; 10(11): 1964–78.
Tangren JS, Powe CE, Ankers E, Ecker J, Bramham K, Hladunewich MA, et al. Pregnancy outcomes after clinical recovery from AKI.
J Am Soc Nephrol
. 2017 May; 28(5): 1566–74.
Alsuwaida A, Mousa D, Al-Harbi A, Alghonaim M, Ghareeb S, Alrukhaimi MN. Impact of early chronic kidney disease on maternal and fetal outcomes of pregnancy.
J Matern Fetal Neonatal Med
. 2011 Dec; 24(12): 1432–6.
Kominiarek MA, Vanveldhuisen P, Hibbard J, Landy H, Haberman S, Learman L, et al. The maternal body mass index: A strong association with delivery route.
Am J Obstet Gynecol
. 2010; 203: 264.e261–267.
Hollowell JG. Outcome of pregnancy in women with a history of vesico-ureteric reflux.
. 2008 Sep; 102(7): 780–4.
Park S, Yoo KD, Park JS, Hong JS, Baek S, Park SK, et al. Pregnancy in women with immunoglobulin A nephropathy: are obstetrical complications associated with renal prognosis?
Nephrol Dial Transplant
. 2018 Mar; 33(3): 459–65.
Attini R, Kooij I, Montersino B, Fassio F, Gerbino M, Biolcati M, et al. Reflux nephropathy and the risk of preeclampsia and of other adverse pregnancy-related outcomes: a systematic review and meta-analysis of case series and reports in the new millennium.
J Nephrol
. 2018 Dec; 31(6): 833–46.
Smyth A, Oliveira GH, Lahr BD, Bailey KR, Norby SM, Garovic VD. A systematic review and meta-analysis of pregnancy outcomes in patients with systemic lupus erythematosus and lupus nephritis.
Clin J Am Soc Nephrol
. 2010 Nov; 5(11): 2060–8.
Verburg PE, Tucker G, Scheil W, Erwich JJ, Dekker GA, Roberts CT. Sexual dimorphism in adverse pregnancy outcomes - a retrospective Australian population study 1981-2011.
PLoS One
. 2016 Jul; 11(7):e0158807.
Dekker GA, Chan A, Luke CG, Priest K, Riley M, Halliday J, et al. Risk of uterine rupture in Australian women attempting vaginal birth after one prior caesarean section: a retrospective population-based cohort study.
. 2010 Oct; 117(11): 1358–65.
Davies MJ, Moore VM, Willson KJ, Van Essen P, Priest K, Scott H, et al. Reproductive technologies and the risk of birth defects.
N Engl J Med
. 2012 May; 366(19): 1803–13.
Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, Levin A, World Kidney Day Steering Committee. What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: reflection on world kidney day and international women’s day.
Am J Nephrol
. 2018; 47(2): 103–14.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.