The Correct Answer is D!

Knowledge to Practice, in collaboration with Mayo Clinic, offers online board review and lifelong learning products in Internal Medicine. With a full pre-assessment, you can identify the topics you’ve mastered and focus your time on topics where you need it the most. Our products have been shown to increase knowledge 75% more than traditional methods in less time.1

Question:

A 28 year-old Hispanic female (gravida 1, para 1) with a 12 year-old son and a history of hypertension and proteinuria presents to your office seeking preconception counseling. Two years ago, a kidney biopsy showed focal segmental glomerulosclerosis. Her baseline creatinine level is 3.2 mg/dL, and proteinuria is found on urinalysis.

Which of the following statements is most accurate?

  1. She is infertile with a creatinine of 3.0 mg/dL or more
  2. There are no adverse fetal outcomes associated with maternal chronic kidney disease
  3. There are no adverse maternal outcomes associated with maternal chronic kidney disease
  4. She is at high risk of end-stage renal disease if she becomes pregnant

Rationale:

This patient has severe chronic kidney disease (CKD) with a GFR of 18, placing her in stage IV CKD. Patients with CKD require careful counseling and monitoring before and during pregnancy. The degree of renal impairment at conception is the most important factor impacting fetal and maternal outcomes. With increasing renal impairment, risks of prematurity, low birth weight, preeclampsia, and risk of progression to end stage renal disease (ESRD) also increase. In addition, degree of proteinuria and hypertension also increase risks of adverse outcome. In stage IV CKD (severe CKD), studies have shown that preterm delivery can be as high as 73%, while low birth weight is observed in 57%, and 64% of patients develop pre-eclampsia. Also, 25% of patients have progression of CKD to ESRD. CKD does decrease fertility, but becoming pregnant is not impossible for this patient. The decision to become pregnant ultimately lies with the patient. However, it should be discussed with the patient that pregnancy will carry increased risk of complications, risk to the fetus, and progression to ESRD at her level of disease. Dialysis is not clinically indicated and would not improve the outcome of pregnancy.

1.  Source: "Comparative Analysis of Pre/Post Assessments of Live/Didactic Course Attendees when compared to Mico-Learning/Online Course Users., "Knowledge to Practice, 2017.