Management of Lupus Nephritis in Pregnancy Professor Catherine Nelson-Piercy Consultant Obstetric Physician Guy’s & St. Thomas’ Hospitals Trust Queen Charlotte’s Hospital London, UK

Lupus nephritis

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Increased risk of pre-eclampsia / FGR / preterm delivery

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Even quiescent lupus nephritis increases risk of fetal loss, especially if hypertensive or proteinuric

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Risk of deterioration is higher with higher serum creatinine

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Chance of successful outcome is lower with higher serum creatinine

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SLE nephropathy may manifest or be diagnosed for the first time in pregnancy

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Delay pregnancy for 6 months after renal flare

Estimated effects of pre-pregnancy renal function on pregnancy outcome and maternal renal function. (Values are estimated % of women or neonates affected) Mean prepregnancy serum creatinine μmol/l

Effects on pregnancy outcome

Loss of >25% renal function

FGR

Preterm

PET

PNM

During pregnancy

Persists post partum

180

65

>90

60

10

70

50

35

On dialysis

>90

>90

75

50

N/a

N/a

N/a

ESRF after 1 yr

Williams, D. et al. BMJ 2008;336:211-215

CKD 1

CKD 3

Stratta et al, J Nephrol 2006 Incidence of pre-eclampsia during pregnancy: comparison between the normal population and nephropathic women.

Lupus nephritis – literature review effect on renal function

Meta-analysis: (N= 362 pregnancies) renal flare in

11-43%

reversible acute renal failure in

3-27%

irreversible loss of renal function in

0-11%

Moroni G, Ponticelli C. The risk of pregnancy in patients with lupus nephritis. J Nephrol 2003; 16: 161-7.

Lupus nephritis

Imbasciatti et al. Nephrol Dialysis Transplant 2009; 24: 519-25 113 pregnancies 81 women pre-existing biopsy-proven LN. Renal Bx performed 7.2 +/- 4.9 years before: 6 class II, 8 class III, 48 class IV 19 class V.

At conception, 49% in complete and 27% partial remission. 9 MC, 1 SB, 5 NNDs. 31 (30%) preterm. 34 (33%) BW