Episode 70b Do Over: Predicting Preeclampsia, the PRAECIS trial

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Nov 16, 2024

Mir Melamed, a maternal-fetal medicine expert at the University of Toronto, dives deep into the complexities of preeclampsia. He discusses the collaborative care model uniting nephrology and maternal-fetal specialists to support high-risk pregnancies. The conversation highlights critical biomarkers like S-Fleet and PLGF that aid in diagnosis and management. Melamed also emphasizes the importance of individualized care for renal disease patients, shedding light on the intricate balance of management during pregnancy. Insights into hypertension management and the clinical applications of diagnostic tools are also shared.

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INSIGHT

Preeclampsia Origin

Preeclampsia is primarily a placental disease, not a kidney disease.
Kidney involvement is a downstream effect of placental ischemia and the release of anti-angiogenic factors.

ADVICE

Using sFlt1:PlGF Ratio

Use the sFlt1:PlGF ratio as an additional tool, not a sole determinant, in managing preeclampsia.
It aids clinical judgment, especially in complex cases, but doesn't replace careful patient assessment.

ANECDOTE

Dialysis Patient Anecdote

Michelle Hladunewich shared a story about a dialysis patient with rising blood pressure.
The patient's sFlt1:PlGF ratio was normal, leading to adjusted ultrafiltration and delivery at 36 weeks.

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The Filtrate:

Joel Topf

Swapnil Hiremath

With Special Guest:

Michelle Hladunewich, Nephrologist at the University of Toronto

Mir Melamed, Maternal-Fetal Medicine at the University of Toronto

Editor

Simon Topf

Show Notes

Priscilla Smith’s letter:

Dear Joel and the Freely Filtered team,

I am a long-time fan of your podcast and was looking forward to hearing your recently aired discussion of the Praecis study of sflt1:PlGF use in preeclampsia. Preeclampsia and renal disease in pregnancy are areas that many nephrologists report a lack of knowledge or confidence in discussing and managing. I am a nephrologist who has been co-leading a renal pregnancy clinic in London while writing a PhD on progression of renal disease in pregnancy. I have had the immense privilege of working with experts and key opinion leaders in preeclampsia research both in the UK and internationally. As you know, preeclampsia is a serious and significant condition contributing to global maternal mortality and is also associated with future CKD and CVD risk so is both relevant and important within our professional group.

Sadly, I found myself disappointed by the episode and felt it was a missed opportunity. I appreciate that you had difficulties obtaining appropriate experts to join the discussion, but perhaps it would have been better to delay production. While you all valiantly proceeded to discuss this important study, the topic is complex and there appeared to be a lack of understanding of the surrounding literature and pathogenesis of preeclampsia. Sadly, the maternal medicine expert’s comments at the end of the podcast added little as she seemed determine to negate any benefit from the results despite declaring she had no experience or expertise in the use of these biomarkers.

There are many people who understand the clinical aspects of preeclampsia as well as having direct experience of the use and utility of these biomarkers who would have been able to contribute much to your conversation. I look forward to future discussions of renal disease in pregnancy on your podcast and would be happy to suggest some expert panellists if you ever find yourself stuck.

Kind regards,

Priscilla

Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in preeclampsia (JCI 2003)

sFlt background: Pathogenesis of Preeclampsia and Therapeutic Approaches Targeting the Placenta (PubMed)

PlGF background: Perspectives on the Use of Placental Growth Factor (PlGF) in the Prediction and Diagnosis of Pre-Eclampsia: Recent Insights and Future Steps (PubMed)

The PRAECIS trial (NephJC | NEJM Evidence)