Renal failure due to mesangiocapillary glomerulonephritis in pregnancy: use of plasma exchange therapy

A 20-year-old female became pregnant 4 years after diagnosis of type I mesangiocapillary glomerulonephritis. Despite normal serum creatinine at conception renal function deteriorated during pregnancy. The use of plasmapheresis and albumin substitution as well as antihypertensive therapy enabled the continuation of the pregnancy from 27 weeks' gestation until a healthy infant could be delivered at 33 weeks. However, an abrupt decline in function at delivery did not reverse and the patient remains dialysis dependent. We conclude that plasma exchange therapy with albumin substitution may be of benefit in women with mesangiocapillary glomerulonephritis when renal function has deteriorated in pregnancy. Stabilization of renal function can allow continuation of the pregnancy until greater fetal maturity makes the delivery of a healthy infant more likely. Although plasma exchange is an experimental therapy, in our hands it appears safe for the fetus and maternal complications were limited to minor vascular access problems. The best prognostic marker in this case was the severity of the most recent renal biopsy rather than the level of renal function or hypertension at the start of pregnancy. This contrasts with most reported cases of pregnancy and primary glomerular disease where irreversible deterioration of renal function was uncommon when renal function at the start of pregnancy was only mildly impaired and hypertension well controlled.