Q.19When and by what method should women be offered renal assessment?

Bibliographic InformationStudy Type & Evidence LevelNumber of PatientsPatient CharacteristicsIntervention & ComparisonFollow-up & Outcome MeasuresEffect SizeStudy SummaryReviewer Comments
Ekbom P;Damm P;Feldt-Rasmussen B;Feldt-Rasmussen U;Molvig J;Mathiesen ER;

2001 Oct

{Ekbom, 2001 35115 /id}
Study Type: Cohort

Evidence level: 2++
240type 1 diabetes

Country: Denmark
Intervention: Microalbuminuria

Comparison: Normal urinary albumin excretion ,nephropathy
Follow-up period:

Outcome Measures: Preterm birth
SGA
Preeclampsia
203 (85%) had normal urinary albumin excretion
26 (11%) had microalbuminuria
11 (5%) had diabetic nephropathy

Preeclampsia: n (%)
Normal: 12 (6)
Microalbuminuria: 11 (42)
Diabetic nephropathy: 7 (64)
P < 0.01

SGA: n (%)
Normal: 4 (2)
Microalbuminuria: 1 (4)
Diabetic nephropathy: 5 (45)
P < 0.001

Pre-term birth (< week 37) n (%)
Normal: 71 (35)
Microalbuminuria: 16 (62)
Diabetic nephropathy: 10 (91)
P < 0.001

Pre-term birth (< week 34) n (%)
Normal: 12 (6)
Microalbuminuria: 6 (23)
Diabetic nephropathy: 5 (45)
P < 0.001
The prevalence of preterm birth is considerably increased in women with microalbuminuria, mainly caused by preeclampsia.
Rosenn, B., Miodovnik, M.

2003

{Rosenn, 2003 29318 /id}
Study Type:
Systematic review - meta-analysis

Evidence level: 2++
Effect of pregnancy on diabetes 11 studies 178 subjects

Effect of nephropathy on pregnancy outcome 10 studies 370 subjects
Diabetes and pregnancy

Country:
Intervention:

Comparison:
Follow-up period:

Outcome Measures: Progression of nephropathy
Chronic hypertension
Preeclampsia
C section
IUGR
Delivery <34 weeks
delivery 34–36 weeks
Delivery >36 weeks
8/11 longitudinal studies determined that pregnancy did not alter the rate of decline in renal function. 3 studies found accelerated progression in women with advanced nephopathy. Only one study used non-pregnant controls (this study did not find accelerated progression) the other studies compared the average rate of decline in renal function to the expected rate of decline in the general nonpregnant population of subjects with diabetic nephropathy.

Outcome of pregnancy in women with diabetic nephrology (from 10 published studies)
Chronic hypertension (%) 23– 77
Preeclampsia (%)15 – 64
Caesarean section (%)63–86 IUGR (%)9–45
Delivery <34 weeks (%)16–45
Most studies suggest that pregnancy is not associated with the development of nephropathy or with accelerated progression of pre-existing nephropathy, but some data suggest that in patients with moderate or advanced renal disease, pregnancy may accelerate progression to end- stage renal disease.

The presence of diabetic retinopathy significantly affects the outcome of pregnancy for three reasons
  1. the increased risk of hypertensive complications
  2. the increased risk of fetal prematurity due to deteriorating maternal hypertension and Preeclampsia; and
  3. the increased risk of fetal growth restriction and fetal distress.
Nielsen LR;Muller C;Damm P;Mathiesen ER;

2006

{Nielsen, 2006 36282 /id}
Study Type: Cohort

Evidence level: 2++
46 pregnant women with type 1 diabetesPregnant women with type 1 diabetes who were referred before gestational age 17 weeks. All were Caucasian women.

Country: Sweden
Intervention:

Comparison:
Follow-up period:

Outcome Measures:
  1. Prevalence of preterm delivery before 34 weeks
  2. Pre-eclampsia
  3. Perinatal mortality
  4. Birth weight
The cohorts were comparable with regard to age, diabetes duration, pre-pregnancy body mass index, HbA1c, mean (SD) blood pressure 121 (13)/71 (8) vs. 121 (14)/73 (8) mmHg and early UAE geometric mean (range) 69 (16–278) vs. 74 (30–287) mg/24 h).

The prevalence of preterm delivery before 34 weeks was reduced from 23% to zero (P = 0.02), preterm delivery before 37 weeks from 62% to 40% (P = 0.15) and pre- eclampsia from 42% to 20% (P = 0.11). Perinatal mortality occurred in 4% vs. 0%. Birth weight was 3124 (767) g vs. 3279 (663) g.
Introduction of early antihypertensive treatment with methyldopa in normotensive pregnant women with type 1 diabetes and microalbuminuria resulted in a significant reduction in preterm delivery before gestational week 34.

From: Evidence tables

Cover of Diabetes in Pregnancy
Diabetes in Pregnancy: Management of Diabetes and Its Complications from Preconception to the Postnatal Period.
NICE Clinical Guidelines, No. 63.
National Collaborating Centre for Women's and Children's Health (UK).
London: RCOG Press; 2008 Mar.
Copyright © 2008, National Collaborating Centre for Women’s and Children’s Health.

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