Postpartum diabetes, HTN exacerbate ESRD risk after preeclampsia

January 24, 2013

Taichung, Taiwan - Women with hypertensive disorders in pregnancy, especially preeclampsia or eclampsia, have an increased risk of later end-stage renal disease (ESRD) that climbs even higher for those who develop postpartum hypertension or diabetes [1].

So concluded Dr I-Kuan Wang (China Medical University Hospital, Taichung, Taiwan) and colleagues based on their analysis of >26 000 Taiwanese women who developed hypertensive disorders during pregnancy from 1998 to 2009; women with a history of hypertension, diabetes, or renal disease were excluded. Their study was published online January 21, 2013 in CMAJ.

In an accompanying editorial [2], Dr Julia J Spaan (Maastricht University Medical Center, the Netherlands) and Dr Mark A Brown (University of New South Wales, Kogarah, Australia) write that the study not only confirms an earlier report showing an increased ESRD risk in women with a history of preeclampsia, "it also confirms that a large component of this risk is the [later] emergence of hypertension and diabetes in these women."

A caveat noted by both the authors and editorialists: the prevalence of ESRD in Taiwan is among the highest in the world and probably higher than in most Western countries. However, that the previous study with similar findings was conducted in Norway may support the current conclusions as generalizable to other countries and ethnic groups, Spaan and Brown propose.

In the current study, the 26 651 women with hypertensive disorders during pregnancy were compared with a cohort of 213 397 women, matched for age and year of pregnancy, who had uncomplicated pregnancies.

The hazard ratio (HR) for chronic kidney disease (CKD) among the women with hypertensive disorders during pregnancy, compared with those without such disorders, was 9.38 (95% CI 7.09-12.4) overall; 7.62 (2.80-20.8) strictly among women who developed postpartum diabetes; and 1.35 (0.94-1.94) only among those who developed postpartum hypertension. The three analyses were adjusted for "urban status, coronary artery disease, congestive heart failure, hyperlipidemia, and abruption."

As for ESRD, women with preeclampsia or eclampsia had a more sharply increased risk (vs controls) compared with the risk (vs controls) in women who had developed only gestational hypertension.



Adjusted HR (95% CI) for ESRD among women with (vs without) hypertensive disorders in pregnancy overall and by type of hypertensive disorder

Hypertensive disorders in pregnancy population
HR (95% CI) a
HR (95% CI) b
Overall
12.4 (8.54-18.0)
2.72 (1.76-4.22)
Pre eclampsia/eclampsia (n=17 998)
14.0 (9.43-20.7)
3.19 (2.02-5.02)
Gestational hypertension (n=8653)        
9.03 (5.20-15.7)
1.81 (0.99-3.30)

a. Adjusted for urban status, coronary artery disease, congestive heart failure, hyperlipidemia, and abruption

b. After further adjustment for hypertension and diabetes during follow-up

Adjusted HR (95% CI) for ESRD among women with (vs without) hypertensive disorders in pregnancy, by postpartum hypertension and diabetes status


Hypertension and diabetes status during follow-up
HR (95% CI)*
Developed postpartum hypertension
1.51 (0.95-2.41)
No postpartum hypertension
6.67 (3.48-12.8)
Developed postpartum diabetes
10.6 (2.31-51.0)
No postpartum diabetes
11.9 (8.09-17.6)

* Adjusted for urban status, coronary artery disease, congestive heart failure, hyperlipidemia, and abruption

"This study by Wang and colleagues is timely because it shows the importance of hypertension during pregnancy as a marker for future chronic kidney disease, cardiovascular disease, and diabetes," write Spaan and Brown.

"It also highlights one of the current pitfalls of clinical practice: although these women have great attention paid to their high blood pressure during pregnancy, there is no structured follow-up of blood pressure or cardiovascular and renal risk factors after pregnancy. Better surveillance after pregnancy should help prevent not only chronic kidney disease but also cardiovascular disease."

Neither the study authors nor the editorialists had disclosures.

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