Xu Joyce H, Czarny Heather N, Toledo Isabella, Warshak Carri R, DeFranco Emily A, Rossi Robert M
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH (XU, Czarny, Toledo, Warshak, DeFranco, Rossi).
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, OH (XU, Czarny, Toledo, Warshak, DeFranco, Rossi).
Am J Obstet Gynecol MFM. 2025 Feb;7(2):101594. doi: 10.1016/j.ajogmf.2024.101594. Epub 2025 Jan 2.
Chronic kidney disease is a significant cause of adverse obstetric outcomes. However, there are few studies assessing the risk of severe maternal morbidity and mortality among patients with chronic kidney disease and no studies assessing the association between individual indicators of severe maternal morbidity and chronic kidney disease.
To evaluate the risk of severe maternal morbidity and mortality among pregnant patients with chronic kidney disease.
This was a population-based, retrospective cohort study including U.S. delivery hospitalizations from 2010-2020 utilizing the Healthcare Cost & Utilization Project National Inpatient Sample database. Patients were identified as having a delivery hospitalization, chronic kidney disease, and severe maternal morbidity using International Classification Diagnoses codes (9 and 10 edition). The primary outcomes were severe maternal morbidity and mortality, as defined according to the Centers for Disease Control and Prevention criteria. Multivariate logistic regression analyses were performed to estimate adjusted relative risk and 95% confidence intervals of severe maternal morbidity and mortality among patients with chronic kidney disease. Subgroup analyses were performed by chronic kidney disease etiology, stage, race and ethnicity, and individual indicators of severe maternal morbidity.
Among the 38,374,326 parturients in this study, 95,272 (0.2%) had chronic kidney disease. The risk of severe maternal morbidity was higher for those with chronic kidney disease (12.2% vs 0.7%, aRR 6.4, 95% CI 6.0-6.8) compared to those without. Among severe maternal morbidity indicators, those with chronic kidney disease were at highest risk for acute renal failure (aRR 21.7, 95% CI 19.8-23.7) and sepsis (aRR 9.0, 95% CI 7.6-10.5). Chronic kidney disease was also associated with an increased risk of maternal death (aRR 4.1, 95% CI 2.9-5.8). Black individuals had higher adjusted population attributable fraction (aPAF) between severe maternal morbidity and chronic kidney disease (aPAF 4.0%, 95% CI 3.6-4.3). Increased risk of severe maternal morbidity was associated with all chronic kidney disease subtypes, stages, and a history of renal transplant. Maternal death was significantly associated with diabetic nephropathy, renovascular, and obstructive or unspecified renal disease (aRR 7.3-14.1), as well as stages 3-5 of chronic kidney disease and a history of renal transplant (aRR 15.5-32.6). Risk of severe maternal morbidity and mortality were similar in those with a history of renal transplant and those with stage 1 chronic kidney disease. The number needed to treat with renal transplant to prevent 1 severe maternal morbidity event or maternal death in those with stages 3-5 chronic kidney disease was 2.6 (95% CI 2.4-2.9) and 45.0 (95% CI 31.0-82.0), respectively.
Chronic kidney disease in pregnancy was significantly associated with severe maternal morbidity, mortality, and other adverse perinatal outcomes, warranting close surveillance and multidisciplinary management throughout pregnancy.
慢性肾脏病是不良产科结局的重要原因。然而，评估慢性肾脏病患者严重孕产妇发病和死亡风险的研究较少，且尚无研究评估严重孕产妇发病的个体指标与慢性肾脏病之间的关联。
评估慢性肾脏病孕妇严重孕产妇发病和死亡的风险。
这是一项基于人群的回顾性队列研究，利用医疗成本与利用项目国家住院样本数据库，纳入了2010年至2020年美国分娩住院病例。使用国际疾病分类诊断编码（第9版和第10版）确定患者为分娩住院、患有慢性肾脏病且发生严重孕产妇发病。主要结局为根据疾病控制和预防中心标准定义的严重孕产妇发病和死亡。进行多因素逻辑回归分析，以估计慢性肾脏病患者严重孕产妇发病和死亡的调整后相对风险及95%置信区间。按慢性肾脏病病因、分期、种族和民族以及严重孕产妇发病的个体指标进行亚组分析。
本研究的38374326名产妇中，95272名（0.2%）患有慢性肾脏病。与未患慢性肾脏病的产妇相比，患慢性肾脏病的产妇发生严重孕产妇发病的风险更高（12.2%对0.7%，调整后相对风险6.4，95%置信区间6.0 - 6.8）。在严重孕产妇发病指标中，患慢性肾脏病的产妇发生急性肾衰竭（调整后相对风险21.7，95%置信区间19.8 - 23.7）和败血症（调整后相对风险9.0，95%置信区间7.6 - 10.5）的风险最高。慢性肾脏病还与孕产妇死亡风险增加相关（调整后相对风险4.1，95%置信区间2.9 - 5.8）。黑人个体在严重孕产妇发病与慢性肾脏病之间的调整后人群归因分数较高（调整后人群归因分数4.0%，95%置信区间3.6 - 4.3）。严重孕产妇发病风险增加与所有慢性肾脏病亚型、分期以及肾移植病史相关。孕产妇死亡与糖尿病肾病、肾血管疾病、梗阻性或未明确的肾脏疾病（调整后相对风险7.3 - 14.1）以及慢性肾脏病3 - 5期和肾移植病史显著相关（调整后相对风险15.5 - 32.6）。肾移植病史患者与1期慢性肾脏病患者的严重孕产妇发病和死亡风险相似。对于3 - 5期慢性肾脏病患者，预防1例严重孕产妇发病事件或孕产妇死亡所需的肾移植治疗数分别为2.6（95%置信区间2.4 - 2.9）和45.0（95%置信区间31.0 - 82.0）。
妊娠期慢性肾脏病与严重孕产妇发病、死亡及其他不良围产期结局显著相关，整个孕期需要密切监测和多学科管理。
