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Nephrol Dial Transplant (2013) 28: 11991206

doi: 10.1093/ndt/gfs573
Advance Access publication 12 January 2013

Pre-eclampsia or chronic kidney disease? The ow hypothesis


1
Clinical and Biological Sciences (Nephrology), University of Torino
Giorgina B. Piccoli1,
(San Luigi), Torino, Italy and
Pietro Gaglioti2, 2
Materno-Foetal Unit, University of Torino, Torino, Italy
2
Rossella Attini ,
Silvia Parisi2,
Carlotta Bossotti2,
Elena Olearo2,

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Manuela Oberto2,
Martina Ferraresi1,
Alessandro Rolfo2,
Elisabetta Versino1,

ORIGINAL ARTICLE
Marilisa Biolcati2
and Tullia Todros2

Correspondence and offprint requests to: Giorgina Keywords: chronic kidney disease, echo-Doppler, placenta
B. Piccoli; E-mail: gbpiccoli@yahoo.it pre-eclampsia, proteinuria, ultrasounds

considered pathological according to the classical cut-point


A B S T R AC T (RI > 0.58). Umbilical ows were evaluated according to stan-
dards adjusted for gestational age. Statistical analysis was per-
Background. Chronic kidney disease (CKD) and pre-eclamp-
formed in SPSS.
sia (PE) occur in 35% of pregnancies. They often share hy- Results. The analysis included 61 cases. The presence of
pertension and proteinuria and a differential diagnosis may be normal FVWs was signicantly associated with the diagnosis
impossible. However, in PE, the pathogenesis is related to ab-
of CKD (P = 0.0018). Conversely, the presence of both altered
normal placentation, which can be detected by abnormal ows was signicantly associated with PE (P = 0.0233).
uterine and umbilical Doppler ow velocities, while in CKD, Conclusions. In the presence of proteinuria and hypertension,
an intrinsic kidney disease is present. We hypothesize that
normal ows suggest CKD altered ows PE. Prospective
Doppler studies can help to differentiate PE from CKD, as the studies are needed to rene this hypothesis based on the rst
ow velocities are altered in PE and normal in CKD. Doppler criteria supporting the differential diagnosis between
Methods. We retrospectively selected patients who were fol-
CKD and PE.
lowed in our Materno-Foetal Unit (200510) and had at least
one ow measurement in our setting. CKD patients were in-
cluded in the presence of proteinuria (300 mg/day) and hy-
pertension, mimicking PE. The clinical charts were reviewed
by the same operators; the clinical diagnoses were taken as re- INTRODUCTION
ference. Three ow patterns were considered: alteration of
both ow velocity waveforms (FVWs) (uterine and umbilical Chronic kidney disease (CKD) and pre-eclampsia (PE) are in-
arteries), hypothesized as predictive of PE; normal FVWs at volved in poor pregnancy outcomes [1, 2]. They share
both levels, hypothesized as predictive of CKD; altered FVW common features but need different treatments, indicating the
in either artery, considered mixed. Uterine FVWs were importance of a differential diagnosis [35]. Both diseases

1199
The Author 2013. Published by Oxford University Press on
behalf of ERA-EDTA. All rights reserved.
typically present with hypertension and proteinuria. Both may GFR below 60 mL/min for the same time period. As the most
have a stormy course with high risks for mother and child. widely used formulae (Cockcroft and Gault and MDRD) have
Both have a high prevalence in Western countries: CKD is esti- serious limits in pregnancy, GFR calculation was based, when-
mated as high as 3% in women in childbearing age and pre- ever possible, on preconception data, within 3 months prior to
eclamptic manifestations complicate 25% of all pregnancies conception, as elsewhere specied [9].
[17]. Hypertension was dened as systolic blood pressure 140
The availability of preconception data should allow the and/or diastolic blood pressure 90 or anti-hypertensive
differential diagnosis between PE and CKD in most cases; therapy; patients on anti-hypertensive therapy prior to con-
however, pregnancy is often the rst occasion in which a ception were classied as affected by chronic hypertension
woman undergoes biochemical tests [1, 2, 4, 5]. Furthermore, even when therapy had been discontinued in pregnancy; they
renal diseases may occur or are up in pregnancy, favoured by were not included in the study unless CKD was present [17].
the hormonal milieu [8, 9]. PE was dened as the appearance of hypertension with sys-
The relationship between PE and CKD is entangled: PE tolic blood pressure 140 mmHg or diastolic blood pressure
affects kidney function, causing proteinuria and hypertension; 90 mmHg accompanied by proteinuria 300 mg/24 h after
a link between PE and CKD has been identied in large-popu- 20 weeks of gestational age in a previously normotensive
lation studies [1, 2, 58]. Conversely, CKD, hypertension and woman; alterations should resolve within 3 months after deliv-
proteinuria are independent risk factors for unfavourable preg- ery [9, 1719].
nancy outcomes and PE [610]. A mixed clinical pattern was identied when a previously
The differential diagnosis between CKD and PE is difcult: normotensive, non-proteinuric patient with known kidney

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physiological hyperltration may mask a moderate reduction disease developed a PE syndrome.
in the glomerular ltration rate (GFR) and consensus on how
to assess GFR or proteinuria in pregnancy has not been
reached [11].
Uterine and umbilical Doppler ow velocity waveforms
(FVWs) are used in the diagnosis and management of PE. Selection of patients
ORIGINAL ARTICLE

It has been shown that abnormal FVWs in the uterine ar- CKD patients were selected from the database of the Out-
teries after 2224 weeks of gestation reect abnormal tro- patient Unit dedicated to kidney diseases in pregnancy, pro-
phoblast invasion of the spiral arteries, which is thought to spectively updated since 2000.
contribute to the pathogenesis of PE [1, 2, 1215]. This To mimic the PE patterns, patients with proteinuria 300
pattern is often associated with abnormal Doppler FVWs in mg/day and hypertension, at the time of the Doppler study
the umbilical arteries, indicating abnormal development of and who had undergone at least one Doppler study in our
the vascular villous tree, which in turn is associated with Unit, were selected. If a patient was proteinuric and hyperten-
foetal growth restriction [1316]. sive before pregnancy, she was considered as CKD; the diag-
The present study aimed at testing the working hypothesis nosis of PE on CKD was done on the case of new onset of
that Doppler FVWs in the umbilical and uterine arteries are proteinuria and hypertension on a previously non-proteinuric
different in PE and CKD. Considering PE as a primary dis- non-hypertensive woman with known CKD.
order of placental implantation, we expected the uterine and Only patients observed since 2005 were included for hom-
umbilical arteries FVWs to be altered in PE patients. In con- ogeneity with the other two archives.
trast, FVWs were expected to be normal in CKD patients, at PE patients were selected from the database of the
least until the late phase of pregnancy. In cases in which PE is Materno-Foetal Unit, gathering all hospitalized patients in the
superimposed over CKD, the pattern was expected to reect Unit since 2005. The diagnosis of PE, as supplied on the clini-
the prevalent disease. cal charts, was reviewed by one nephrologist and two obstetri-
cians.
The Doppler studies were obtained from the archives of the
METHODS Materno-Foetal Unit where all tests have been stored since
2005. Only studies since the 26th gestational week were con-
Clinical denitions sidered, for the sake of standard reference values. If more were
Three referral clinical categories were dened: CKD, PE available for the same patient, the rst one after the 26th gesta-
and mixed (PE on CKD). tional week was selected. Only singletons were included.
CKD patients were either referred from a nephrology unit, Out of 78 patients, initially identied from the 3 different
were they were followed for different types of kidney diseases, archives, 61 cases were selected for the nal evaluation (5 PE
diagnosed according to the usual criteria or diagnosed as with patients were excluded, reclassied as pregnancy-induced hy-
CKD during pregnancy; all these patients were referred to a pertension; 1 patient was excluded because of twin pregnancy;
nephrology unit after delivery and the diagnosis of CKD was 2 patients because of incomplete data; 9 patients because the
conrmed in all cases. ow measurement was performed before 26 weeks of gesta-
CKD was classied according to K-DOQI guidelines as tional age, when the results are not yet standardized). One
every anomaly of blood and urine composition, or imaging or patient (two pregnancies) initially in the PE group was reclas-
pathological data, lasting for at least three months or with a sied as affected by a mixed pattern.

1200
G.B. Piccoli et al.
Table 1. Baseline data of the 61 cases
Clinical Patients Maternal age Race Parity (rst BMI Proteinuria before
subset at start pregnancy delivery: g/day
of pregnancy %) (median)
(years)
CKD 17 29.9 5.7 Caucasian 12 9 (52.9%) 22.8 4.0 2.05 (0.3317.29)
(70.6%)
Asian 3
(17.6%)
African 1
(5.9%)
Other 1
(5.9%)
PE 39 32 4.8 Caucasian 34 31 (79.5%) 24.8 5.2 1.52 (0.326)
(87.2%)
African 4

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(10.2%)
Other 1
(2.6%)
Mixed 5 33 3.1 Caucasian 5 3 (60%) 21.9 3.2 0.38 (0.39.41)
pattern (100%)

ORIGINAL ARTICLE
All cases 61 32 5.1 Caucasian 51 43 (70.5%) 24 4.8 2 (0.317.29)
(83.6%)
Asian 3
(4.9%)
African 5
(8.2%)
Other 2
(3.3%)
Note: no signicant difference in baseline data among groups.

Doppler ow studies data proposed by Todros et al. [16]. Abnormal patterns of um-
The evaluation of the uterine arteries took into account the bilical artery Doppler waveforms, especially absence or rever-
resistance index (RI) or Pourcelot ratio, dened as peak systo- sal of end-diastolic velocities, were also recorded.
lic ow minus peak end diastolic ow divided by peak systolic Flow denitions. Three major simplied ow patterns
ow. were identied: alteration of both FVWs (uterine and umbili-
According to the literature, an abnormal uterine artery cal arteries), hypothesized as predictive of PE; normal FVWs
Doppler FVW was dened as a mean (of the two uterine ar- at both levels, hypothesized as predictive of CKD; altered
teries) RI of 0.58; a further more restrictive cut-point (0.62) FVW in either artery, considered mixed. The studies were
was also tested. Both cut-points are standardized references, performed by the same small team of operators, working to-
and are applied to gestational ages of at least 26 weeks. The gether for over 10 years.
uterine ows are not physiologically variable with the gesta-
tional age thereafter, and not age adjusted [1316]. Statistical analysis
The presence of early diastolic notching in the waveform of
the main uterine arteries was underlined, especially if bilateral A descriptive analysis was performed as appropriate (mean
[1316]. and standard deviation for parametric and median and range
Umbilical artery Doppler waveforms were analysed using for non-parametric data). Students t-test and log rank (when
the Pulsatility index (PI), dened as peak systolic ow minus appropriate), Chi-square test and ANOVA were used for com-
end diastolic ow divided by mean ow. Normal values of PI parisons between cases and controls and among groups. Sig-
were adjusted for gestational age, after the 26th gestational nicance was set at <0.05. Both RI cut-points (0.58 and 0.62)
week, and were dened according to gestational age-adjusted were tested. The tests were also stratied by operator of the
study.

1201
Pre-eclampsia or chronic kidney disease, Doppler criteria
Accuracy of both normal ows in predicting CKD and of

termination
both abnormal ows in predicting PE was summarized
through sensitivity, specicity, positive predictive value (PPV),

Death-
negative predictive value (NPV), positive likelihood ratio (LH

2.6%

1.6%

NS


+) and negative likelihood ratio (LH), with their 95% con-
dence intervals (95% CI); signicance of differences was tested
with Chi-square test.

31 (79.5%)

40 (65.6%)
6 (35.3%)
NICU (%)
The analysis was performed with the SPSS software

3 (60%)
Need for

0.0013
(version 18.0).

NICU, Neonatal Intensive Care Unit; SGA, small for gestational age baby, according to the Italian reference standards; week, gestational week; NS, non-signicant
R E S U LT S

38 (97.4%)

54 (88.5%)
11 (64.7%)

5 (100%)
Caesarean
Baseline characteristics and outcome data

section

0.0030
The main clinical data of the 61 cases are reported in

(%)
Table 1, according to the three main clinical categories. No sig-
nicant difference was observed for demographic data in the
different subsets.
The CKD group consisted of 17 patients; 7 in stage 1; 2 in

4 (10.2%)
score (50 )

4 (6.6%)

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stage 2 CKD; 5 in stage 3 and 3 in stage 4; the kidney diseases

<7 (%)
Apgar
were: glomerulonephritis [6], kidney malformation [1], pre-

NS


vious acute pyelonephritis, with scars, [1], interstitial nephro-
pathy [4], Adult dominant polycystic kidney disease
(ADPKD) [1], kidney transplant [1], solitary kidney [1] and

17.6% (23.5%)
15.6% (28.1%)

16.7% (27.8%)
diabetic nephropathy [2].

20% (40%)
The ve patients with a mixed pattern of PE on CKD were
ORIGINAL ARTICLE

SGA: <5th
centile %
(% < 10)
two in stage 1 and three in stage 2 CKD, and were affected by
glomerulonephritis [3], ADPKD [1] and nephrolithiasis [1].

NS
The overall prognosis was better in the CKD patients than
in the PE patients, with a signicantly lower incidence of
preterm babies (deliveries <37 weeks: 76.5 versus 97.4%,
2028.4 682.1
1362.9 609.5
1416 373.6

1552.7 676.6
P = 0.0434; deliveries 34 weeks: 47.1 versus 92.3%,
Birth weight

P = 0.0006) and caesarean sections (64.7 versus 97.4%,


P = 0.0030), while the prevalence of small for gestational age

0.0006
Table 2. Perinatal outcome data in the study population

babies, according to the Italian standards [20], was not signi-


cantly different between the groups (<10th centile: 23.5 versus
28.1%, P = ns) (Tables 1 and 2).z
weeks (34 weeks)

Relationship between clinical diagnosis and ow pattern


76.5% (47.1%)
97.4% (92.3%)

91.8% (78.7%)
100% (80%)
Preterm % <37

Figure 1 reports the results of the 61 Doppler tests, sorted


according to the clinical diagnosis (the normal uterine ow
0.0434

cut-point set at RI 0.58). Normal ows in both uterine and


umbilical arteries were found in 10/17 CKD (58.8%) and in 7/
39 PE (17.9%); pathological ows in both arteries were found
in 1/17 CKD (5.9%) and in 20/39 PE (51.3%); a mixed ow
was found in the remaining tests (Table 2).
34.5 3.1
31.1 3.0
32 3.6

32.1 3.3

0.0003

The differences were also statistically signicant when the


cut-point of 0.62 was used: in the whole subset, P = 0.002 con-
Week

sidering all normal ows in the prediction of CKD, P = 0.037


considering both abnormal ows in the prediction of PE. Stat-
istical signicance rose remarkably when the cases with
mixed ow patterns were excluded (Table 3), thus allowing
5
17
39

61
n

the design of a ow chart to support the differential diagnosis


between CKD in pregnancy and PE (Figure 2).
Both normal ows are highly predictive of absence of CKD
Clinical

pattern
Mixed

(NPV = 0.95; 95% CI = 0.770.99), while both abnormal ows


subset

versus
CKD)
P (PE
CKD

cases
All
PE

are highly predictive of the presence of PE (PPV = 0.95; 95%


CI = 0.770.99) (Table 4).

1202
G.B. Piccoli et al.
F I G U R E 1 : Comparison between clinical diagnosis and ow pattern.

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Table 3. Analysis of umbilical and uterine ows in the prediction of CKD and PE
Both normal Both Mixed P (X2 test) Both P (X2 test) Both

ORIGINAL ARTICLE
ows, n (%) abnormal pattern, n (%) normal ows in the abnormal ows in the
ows, n (%) prediction of CKD prediction of PE
All cases
All 18 (29.5) 24 (39.3) 19 (31.2) CKD versus PE + PE PE versus CKD + PE
patients on CKD; P = 0.0018 on CKD; P = 0.0233
CKD 10 (58.8) 1 (5.9) 6 (35.3)
PE 7 (17.9) 20 (51.3) 12 (30.8)
PE on 1 (20) 3 (60) 1 (20)
CKD
Either both normal or both abnormal ows (mixed ow pattern excluded)
All 18 (42.9) 24 (57.1) CKD versus PE + PE PE versus CKD + PE
patients on CKD; P = 0.0007 on CKD; P = 0.0081
CKD 10 (90.9) 1 (9.1)
PE 7 (25.9) 20 (74.1)
PE on 1 (25) 3 (75)
CKD
PE versus CKD only: all cases
All 17 (30.4) 21 (37.5) 18 (32.1) CKD versus PE; PE versus CKD;
patients P = 0.0022 P = 0.0034
CKD 10 (58.8) 1 (5.9) 6 (35.3)
PE 7 (17.9) 20 (51.3) 12 (30.8)
PE versus CKD only: either both normal or both abnormal ows (mixed ow pattern excluded)
All 17 (44.7) 21 (55.3) CKD versus PE; PE versus CKD;
patients P = 0.0010 P = 0.0010
CKD 10 (90.9) 1 (9.1)
PE 7 (25.9) 20 (74.1)

1203
Pre-eclampsia or chronic kidney disease, Doppler criteria
Table 4. Accuracy of both normal ows in predicting CKD and of both abnormal ows in
predicting PE (mixed ow pattern and PE on CKD excluded)
Test disease Sensitivity Specicity PPV NPV LH + (IC95%) LH P-value
(IC95%) (IC95%) (IC95%) (IC95%) (IC95%)
Both normal 0.91 0.74 0.59 0.95 3.51 0.12 0.001
ows: (0.620.98) (0.550.87) (0.360.78) (0.770.99) (1.806.81) (0.020.81)
prediction of
CKD
Both 0.74 0.91 0.95 0.59 8.15 0.27 0.001
abnormal (0.550.86) (0.620.98) (0.770.99) (0.360.78) (1.2453.51) (0.150.55)
ows:
prediction of
PE

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ORIGINAL ARTICLE

F I G U R E 2 : Summary suggestions according to the ow pattern in patients presenting with proteinuria and hypertension in pregnancy. Basic
nephrological evaluation includes clinical history, as recorded by the nephrologist, renal clearances, GFR assessment by the common formulae,
24 h proteinuria, kidney and urinary tract ultrasounds. Extensive evaluation includes all of the above plus serum and urinary electrolytes, acid
base balance, basic immunological data and further tests tailored to the most likely clinical hypothesis.

Finally, as the LR+ is the likelihood of a given result in a attention over follow-up, a potentially relevant suggestion in
patient with the target disorder, both normal ows display a clinical practice (Figure 2).
3.5 times higher likehood to be found in CKD than in PE and In our study, there was no difference, or gradation, in arter-
both abnormal ows are 8 times more likely in PE, when com- ial ow patterns in patients with or without GFR loss or ac-
pared with CKD (Table 4). cording to proteinuria; minor differences linked to the
diseases as well as to ethnicity or to other factors may,
however, be evident only in much larger cohorts.
Our data support the concept that proteinuria and hyper-
DISCUSSION tension in CKD and PE do not share the same pathogenesis
and that they may not have the same effect on the foetus
The main results of our study identify two main ow patterns, (Table 3). In PE, a primary defect of placentation is presently
one highly suggestive of CKD (both normal ows) and one considered the trigger for a series of events ultimately resulting
highly suggestive of PE (both altered ows) (Table 3, Figures 1 in generalized endothelial dysfunction via oxidative stress; the
and 2). The differences were statistically signicant (normal highly signicant correlation with the presence of altered
ows in discriminating CKD versus PE: P = 0.0018; abnormal ows, mirroring the presence of an abnormal placental vascu-
ows identifying PE versus CKD: P = 0.0233). The intermedi- lar tree, supports this interpretation [1, 2, 12]. Conversely, the
ate patterns (mixed ows, grouping cases with one normal presence of normal uterine and placental ows, highly predic-
and one abnormal ow) can be interpreted as needing further tive of CKD, supports the hypothesis that in CKD the

1204
G.B. Piccoli et al.
endothelial dysfunction is limited to the kidney and does not
affect placental development. ETHICAL COMMITTEE
The strength of this paper is its novelty: it represents the
rst attempt to apply Doppler criteria to differentiate between The study was approved by the Ethics Committee of the San-
CKD and PE, indeed showing a highly signicant correlation tAnna Hospital, University of Torino. No test was performed
between the ow pattern and the two diseases. The correlation for the sake of the present analysis, which relied on routine
is highly relevant from the clinical point of view, strongly clinical assessments.
suggesting the presence of either PE or CKD in patients with
both abnormal or both normal uterine and umbilical ow
patterns and identifying an intermediate pattern, mainly con- AC K N O W L E D G E M E N T S
sisting in normal umbilical and altered uterine ows, requiring
further clinical attention (Figure 2). To Dr. Peter Christie for his careful language revision.
This study has several limitations, partly shared by retro-
spective studies: it relies on clinical denitions, which are
qualitative and with a degree of approximation; it evaluates the FUNDING
data according to the clinical charts and the different archives,
No nancial support was obtained for this study. The results
built for different purposes; the numbers are not high enough
presented in this paper have not been published previously in
to allow stratication by important parameters, such as gesta-
whole or part, except in abstract format.
tional age at test, level of proteinuria, CKD stage and type of

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therapy.
Since CKD and PE are complex umbrella terms under
which several diseases are grouped, expecting a single bio- C O N F L I C T O F I N T E R E S T S TAT E M E N T
chemical or imaging marker to fully discriminate between the
None declared.
two conditions is probably an oversimplication. Furthermore,
while the clinical diagnosis of CKD is usually controlled over

ORIGINAL ARTICLE
time, the diagnosis of PE is mainly based on the absence of REFERENCES
evidence of other diseases, and it should be controlled over
time, a difcult task in current clinical practice. 1. Steegers EAP, von Dadelszen P, Duvekot JJ et al. Pre-eclampsia.
Nevertheless, within the limits shared by the retrospective Lancet 2010; 376: 631644
assessment of new diagnostic tools, Doppler ow studies may 2. Young BC, Levine RJ, Karumanchi SA. Pathogenesis of pree-
provide valuable help in differentiating between CKD and PE, clampsia. Annu Rev Pathol Mech Dis 2010; 5: 173192
at least in a signicant percentage of cases (Figures 1 and 2). 3. Blacker GF. The albuminuria of pregnancy and the kidney of
Yet, an important subset of cases escapes from this algorithm: pregnancy. Lancet 1905; 4295: 18191822
CKD patients who are neither proteinuric nor hypertensive 4. Kincaid Smith P, Fairley KF. The differential diagnosis between
(as may occur in early polycystic kidney disease or interstitial preeclamptic toxemia and glomerulonephritis in patients with
salt-losing nephropathies), or who display proteinuria in the proteinuria during pregnancy. Perspect Nephrol Hypertens 1976;
absence of hypertension (as may be observed in several 5: 157167
primary glomerular diseases of the young). Hence, our algor- 5. Williams D, Davison J. Chronic kidney disease in pregnancy.
ithm does not replace other diagnostic clues of CKD in preg- BMJ 2008; 336: 211215
nancy (such as recurrent urinary tract infections or electrolyte 6. Vikse BE, Irgens LM, Leivestad T et al. Preeclampsia and the risk
imbalance). of end-stage renal disease. N Engl J Med 2008; 359: 800809
These limitations identify points to be developed in a pro- 7. American College of Obstetricians and Gynecologists. Diagnosis
spective clinical study, systematically collecting ultrasound and management of preeclampsia and eclampsia. ACOG Practice
data on PE and CKD patients and following them for 6 Bulletin No 22. Obstet Gynecol 2002; 99: 159167
months after delivery. Such a study is presently being planned 8. Vidaeff AC, Yeomans ER, Ramin SM. Pregnancy in women with
in our Unit. renal disease. Part I: general principles. Am J Perinatol 2008; 25:
385397
9. Piccoli GB, Attini R, Vasario E et al. Pregnancy in chronic kidney
disease: a challenge in all CKD stages. Clin J Am Soc Nephrol
2010; 5: 844855
10. Jones DC, Hayslett JP. Outcome of pregnancy in women with
CONCLUSIONS moderate or severe renal insufciency. N Engl J Med 1996; 335:
226322
The analysis of utero-placental arterial ows in patients with 11. Alper AB, Yi Y, Rahman M et al. Performance of estimated glo-
proteinuria and hypertension occurring or discovered during merular ltration rate prediction equations in preeclamptic
gestation may help identify patients with underlying CKD, patients. Am J Perinatol 2011; 28: 425430
thus facilitating tailored follow-up during pregnancy and 12. Redman CW, Sargent IL. Latest advances in understanding pree-
timely interventions after delivery. clampsia. Science 2005; 308: 15921594

1205
Pre-eclampsia or chronic kidney disease, Doppler criteria
13. Cnossen JS, Morris RK, terRiet G et al. Use of uterine artery proteinuria early in the course of pregnancy (before 20 weeks)
Doppler ultrasonography to predict pre-eclampsia and intrauter- is likely to reect underlying CKD whilst late onset changes in
ine growth restriction: a systematic review and bivariable meta- renal function, urine protein excretion and blood pressure are
analysis. CMAJ 2008; 178: 701711 more likely to be diagnostic of PE. In other words, is the pre-
14. Hoffman C, Galan HL. Assessing the at risk fetus: Doppler ul- dictive value of uterine blood ow at differentiating between
trasounds. Curr Opi Obstet Gynecol 2009; 21: 161166 PE and CKD any better than the simple urine dipstick for pro-
15. Meler E, Figueras F, Mula R et al. Prognostic role of uterine teinuria at booking (which is usually between 6-12 weeks)? If
artery Doppler in patients with preeclampsia. Fetal Diagn Ther disptick at booking is abnormal then highly likely to be CKD!
2010; 27: 813
16. Todros T, Ronco G, Fianchino O et al. Accuracy of the umbilical So the questions really are:
arteries Doppler ow velocity waveforms in detecting adverse
perinatal outcomes in a high-risk population. Acta Obstet 1. Isnt the time of onset of the symptoms sufciently dis-
Gynecol Scand 1996; 75: 113119 criminatory to differentiate between CKD and PE?
17. Leeman L, Fontaine P. Hypertensive disorders of pregnancy. Am 2. As microalbuminuria in mid-pregnancy may be a signi-
Fam Physician 2008; 78: 93100 cant predictor of development of subsequent pre-eclampsia
18. National Collaborating Center for Womens and Childrens (2).
Health: Antenatal Care: Routine Care For the Healthy Pregnant Is early urinary testing in pregnancy for microalbuminuria,
Woman. Clinical Guideline, London Royal College of Obstetri- useful in discriminating between these two entities; those with
cians and Gynecologists Press, London, 2008 CKD would have early (before 15 weeks) abnormal urinary

Downloaded from http://ndt.oxfordjournals.org/ by guest on November 14, 2015


19. Intrapartum care: Care for Healthy Women and their Babies albumin excretion (microalbuminuria) whilst those with PE
During Childbirth. NICE Clinical Guideline 55. London: National would develop it later (after 15 weeks)?
Institute for Health and Clinical Excellence, 2007 3. How does the Doppler testing with changing in blood
20. Parazzini F, Cortinovis I, Bortolus R et al. Standards of birth ow velocity waveforms compare to other PE predictors such
weight in Italy. Ann Ostet Ginecol Med Perinat 1991; 112: as serum uric acid but also earlier predictors such as adiponec-
20346 tin, ADAM12, f-hCG, Inhibin A, Activin A, PP13, PlGF, and
ORIGINAL ARTICLE

PAPP-A alone or in combination?


An integrated approach combining biomarkers may yield a
B LO G C O M M E N TA R Y higher predictive value for PE early in pregnancy (3). These
would not be expected to be affected by underlying mild CKD.
NDT ERA-EDTA OLA has selected this publication for Blog com- This topic is of considerable research and clinical interest.
mentary by its faculty in view of its quality and potential edu- An integrated approach to the early differentiation between
cational value Find more on our home page: http://www. underlying CKD and new onset PE may rely on early testing
gkaonlineacademy.com/ndt and clinical evaluation of those at higher risk of PE.

Piccoli and colleagues use umbilical and uterine Doppler


blood ow changes and increased resistance index to differen- Prof Meguid El Nahas
tiate in pregnancy between CKD and pre-eclampsia (PE).
They hypothesize that individuals with high resistance index
reecting impaired umbilical and placental blood ow velocity
are more likely to suffer from PE in the face of hypertension REFERENCES
and proteinuria in pregnancy compared to those whose protei-
nuria and hypertension is more likely to reect CKD. Their 1. Everett TR, Lees CC. Beyond the placental bed: Placental and sys-
observation supports previous analysis suggesting that an in- temic determinants of the uterine artery Doppler waveform. Pla-
creased pulsatility index with notching was the best predictor centa. 2012 Nov;33(11):893901.
of pre-eclampsia amongst high-risk patients and that it also 2. Singh R, Tandon I, Deo S, Natu SM. J Obstet Gynaecol Res. 2012
accurately predicted intrauterine growth restriction among Aug 26. doi: 10.1111/j.1447-0756.2012.01988.
low-risk patients (1). 3. Kuc S, Wortelboer EJ, van Rijn BB, Franx A, Visser GH, Schielen
PC. Evaluation of 7 serum biomarkers and uterine artery Doppler
The NDT ERA-EDTA OLA readers may be interested to learn ultrasound for rst-trimester prediction of preeclampsia: a sys-
more from the authors of this very interesting article about: tematic review. Obstet Gynecol Surv. 2011 Apr;66(4):22539.
The timing of the testing is key to the diagnosis and differ-
entiation between CKD and PE; presence of hypertension and Received for publication: 6.7.2012; Accepted in revised form: 20.11.2012

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