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Gestational Proteinuria Amplification IgAN — ESENeph MCQ

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HardPregnancy & RenalGestational Proteinuria Amplification IgANESENeph

A 29-year-old woman at 20 weeks' gestation with known CKD G2 (eGFR 78 mL/min/1.73m2) secondary to IgA nephropathy presents with uPCR rising from 50 to 180 mg/mmol. BP is 134/84 mmHg on labetalol 200 mg BD. Platelet count, LFTs, and uric acid are normal. sFlt-1:PlGF ratio is 28 (normal). What is the most likely cause of worsening proteinuria?

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Correct answer: B — Physiological gestational increase in proteinuria plus underlying IgAN activity

At 20 weeks with normal sFlt-1:PlGF ratio (<38), normal platelets, normal LFTs, and only modest BP elevation, pre-eclampsia is unlikely. The most probable explanation is physiological gestational increase in proteinuria superimposed on her pre-existing IgAN. Pregnancy causes increased renal plasma flow and GFR (up to 50%), which increases glomerular filtration of protein. In women with underlying glomerular disease, this haemodynamic change amplifies pre-existing proteinuria. The sFlt-1:PlGF ratio <38 has high negative predictive value for pre-eclampsia in the following 1-2 weeks. Close monitoring is essential, as pre-eclampsia can still develop later.

Reference: Bramham et al 2011 – Pregnancy Outcomes CKD; Zeisler et al 2016 – sFlt-1:PlGF Ratio