Characteristics and Outcomes of Patients With Pregnancy-Related End-Stage Kidney Disease.

Characteristics and Outcomes of Patients With Pregnancy-Related End-Stage Kidney Disease.

This cohort study evaluates characteristics and clinical outcomes of patients with pregnancy-related end-stage kidney disease. What are the long-term outcomes of patients with pregnancy-related end-stage kidney disease (ESKD)? This cohort study of 183 640 women found that Black patients were overrepresented among those with pregnancy-related ESKD compared with the general birthing population (31.9% vs 16.2%). Compared with reproductive age patients with other causes of ESKD, those with pregnancy-related ESKD were significantly less likely to have access to kidney transplant or nephrology care before ESKD onset, despite having equivalent or better survival with ESKD. These findings suggest there are significant disparities in access to kidney transplant and nephrology care in this disproportionately Black population; improving postpartum care should be a priority. The incidence of pregnancy-related acute kidney injury is increasing and is associated with significant maternal morbidity including progression to end-stage kidney disease (ESKD). Little is known about characteristics and long-term outcomes of patients who develop pregnancy-related ESKD. To examine the characteristics and clinical outcomes of patients with pregnancy-related ESKD and to investigate associations between pre-ESKD nephrology care and outcomes. This was a cohort study of 183 640 reproductive-aged women with incident ESKD between January 1, 2000, and November 20, 2020, from the US Renal Data System and maternal data from births captured in the US Centers for Disease Control and Prevention publicly available natality data. Data were analyzed from December 2022 to June 2023. Pregnancy-related primary cause of ESKD, per International Classification of Diseases, Ninth Revision (ICD-9) and ICD-10 codes reported at ESKD onset by the primary nephrologist on Centers for Medicare and Medicaid Services form 2728. Multivariable Cox proportional hazards and competing risk models were constructed to examine time to (1) mortality, (2) access to kidney transplant (joining the waiting list or receiving a live donor transplant), and (3) receipt of transplant after joining the waitlist. A total of 341 patients with a pregnancy-related primary cause of ESKD were identified (mean [SD] age 30.2 [7.3]). Compared with the general US birthing population, Black patients were overrepresented among those with pregnancy-related ESKD (109 patients [31.9%] vs 585 268 patients [16.2%]). In adjusted analyses, patients with pregnancy-related ESKD had similar or lower hazards of mortality compared with those with glomerulonephritis or cystic kidney disease (adjusted hazard ratio [aHR], 0.96; 95% CI, 0.76-1.19), diabetes or hypertension (aHR, 0.49; 95% CI, 0.39-0.61), or other or unknown primary causes of ESKD (aHR, 0.60; 95% CI, 0.48-0.75). Despite this, patients with pregnancy-related ESKD had significantly lower access to kidney transplant compared with those with other causes of ESKD, including (1) glomerulonephritis or cystic kidney disease (adjusted subhazard ratio [aSHR], 0.51; 95% CI, 0.43-0.66), (2) diabetes or hypertension (aSHR, 0.81; 95% CI, 0.67-0.98), and (3) other or unkown cause (aSHR, 0.82; 95% CI, 0.67-0.99). Those with pregnancy-related ESKD were less likely to have nephrology care or have a graft or arteriovenous fistula placed before ESKD onset (nephrology care: adjusted relative risk [aRR], 0.47; 95% CI, 0.40-0.56; graft or arteriovenous fistula placed: aRR, 0.31; 95% CI, 0.17-0.57). In this study, those with pregnancy-related ESKD had reduced access to transplant and nephrology care, which could exacerbate existing disparities in a disproportionately Black population. Increased access to care could improve quality of life and health outcomes among these young adults with high potential for long-term survival.

这项队列研究评估了妊娠相关终末期肾病患者的特征和临床结局。 妊娠相关终末期肾病（ESKD）患者的长期结局如何？ 这项对183640名女性进行的队列研究发现，与一般生育人群相比，黑人患者在妊娠相关ESKD患者中所占比例过高（31.9%对16.2%）。与因其他原因导致ESKD的育龄患者相比，妊娠相关ESKD患者在ESKD发病前获得肾移植或肾病治疗的可能性明显更低，尽管其ESKD生存率相当或更高。 这些研究结果表明，在这个黑人比例过高的人群中，在获得肾移植和肾病治疗方面存在显著差异；改善产后护理应是优先事项。 妊娠相关急性肾损伤的发病率正在上升，并与包括进展为终末期肾病（ESKD）在内的显著的孕产妇发病率相关。对于发生妊娠相关ESKD的患者的特征和长期结局知之甚少。 为了研究妊娠相关ESKD患者的特征和临床结局，并调查ESKD发病前的肾病治疗与结局之间的关联。 这是一项队列研究，研究对象是2000年1月1日至2020年11月20日期间来自美国肾脏数据系统的183640名育龄期发生ESKD的女性，以及来自美国疾病控制与预防中心公开的出生数据中所记录的孕产妇数据。数据分析时间为2022年12月至2023年6月。 根据医疗保险和医疗补助服务中心2728表格上主要肾病医生在ESKD发病时报告的国际疾病分类第九版（ICD - 9）和ICD - 10编码，确定ESKD的妊娠相关主要病因。 构建了多变量Cox比例风险和竞争风险模型，以研究（1）死亡时间、（2）获得肾移植的时间（进入等待名单或接受活体供体移植）以及（3）进入等待名单后接受移植的时间。 共确定了341名ESKD妊娠相关主要病因的患者（平均[标准差]年龄30.2[7.3]岁）。与美国一般生育人群相比，黑人患者在妊娠相关ESKD患者中所占比例过高（109名患者[31.9%]对585268名患者[16.2%]）。在校正分析中，与肾小球肾炎或囊性肾病（校正风险比[aHR]，0.96；95%置信区间，0.76 - 1.19）、糖尿病或高血压（aHR，0.49；95%置信区间，0.39 - 0.61）或其他或未知ESKD主要病因（aHR，0.60；95%置信区间，0.48 - 0.75）的患者相比，妊娠相关ESKD患者的死亡风险相似或更低。尽管如此，与其他原因导致ESKD的患者相比，妊娠相关ESKD患者获得肾移植的机会明显更低，包括（1）肾小球肾炎或囊性肾病（校正亚风险比[aSHR]，0.51；95%置信区间，0.43 - 0.66），（2）糖尿病或高血压（aSHR，0.81；95%置信区间，0.67 - 0.98），以及（3）其他或未知原因（aSHR，0.82；95%置信区间，0.67 - 0.99）。妊娠相关ESKD患者在ESKD发病前接受肾病治疗或放置移植物或动静脉瘘的可能性更低（肾病治疗：校正相对风险[aRR]，0.47；95%置信区间，0.40 - 0.56；放置移植物或动静脉瘘：aRR，0.31；95%置信区间，0.17 - 0.57）。 在这项研究中，妊娠相关ESKD患者获得移植和肾病治疗的机会减少，这可能会加剧黑人比例过高人群中现有的差异。增加获得治疗的机会可以提高这些具有长期生存高潜力的年轻成年人的生活质量和健康结局。