History of Preeclampsia Associated With Increased CKD, ESKD Risk

For many pregnant people, preeclampsia-related hypertension resolves after delivery, but questions linger about whether the kidneys fully recover as well.

Research reveals a potential link between preeclampsia and increased risks of chronic kidney disease, urging careful monitoring post pregnancy. | Image credit: Pituk - stock.adobe.com

That uncertainty framed a recent systematic review and meta-analysis published in International Urology and Nephrology, which evaluated whether preeclampsia was associated with the later development of chronic kidney disease (CKD) or end-stage kidney disease (ESKD) among people who were healthy prior to pregnancy.¹ The analysis was designed to address a persistent limitation of earlier research: the frequent inclusion of participants with preexisting hypertension or kidney disease, which may have inflated risk estimates and obscured questions of causality.

Preeclampsia is a multisystem pregnancy complication characterized by new-onset hypertension after 20 weeks’ gestation, often accompanied by proteinuria or other signs of organ dysfunction.2 Although it is typically considered a transient condition that resolves after delivery, the renal endothelial injury observed during preeclampsia has raised concern that it may either trigger or unmask long-term kidney damage.

The investigators limited their review to studies involving individuals without documented chronic hypertension or kidney disease before pregnancy.1 The authors screened 2796 records from PubMed-MEDLINE and Embase and ultimately included 9 observational studies published between 2000 and 2024, encompassing more than 6.1 million participants. Of these, approximately 210,700 had experienced at least 1 pregnancy complicated by preeclampsia, while nearly 6 million served as controls with uncomplicated pregnancies.

Most of the included studies were retrospective, registry-based cohort analyses conducted in Europe, North America, and Asia; only 1 was a prospective cohort study. Follow-up periods ranged from a mean of 5 years to more than 30 years. Definitions of preeclampsia and kidney outcomes varied across studies, reflecting changes in diagnostic criteria over time.

In pooled analyses using a random-effects model, preeclampsia was associated with a significantly increased relative risk of both CKD and ESKD later in life. The meta-analytic risk ratio for CKD was 1.83 (95% CI, 1.16-2.89), while the corresponding risk ratio for ESKD was 8.96 (95% CI, 4.94-16.23). However, both estimates were accompanied by high statistical heterogeneity (I² > 90%), limiting their generalizability.

Importantly, the only prospective study included in the review did not identify a statistically significant association between preeclampsia and incident CKD over approximately 8 years of follow-up. By contrast, several large retrospective studies reported elevated risks, particularly for glomerular or proteinuric forms of kidney disease and for individuals who experienced preterm delivery, small-for-gestational-age infants, or recurrent preeclampsia.

Absolute risk remained low across studies. In one large UK cohort, the cumulative incidence of CKD after preeclampsia was 1.3% over more than 2.5 million person-years of follow-up, corresponding to a hypothetical number needed to screen of approximately 150 to identify 1 additional CKD case. Similar findings were reported elsewhere, suggesting that although relative risks were elevated, the overall burden of disease attributable to preeclampsia was modest.

The authors emphasized that these findings should be interpreted cautiously. “Although a significant association was identified, its clinical relevance and causality remain unclear,” they wrote, noting that high heterogeneity and residual confounding persisted despite efforts to restrict analyses to previously healthy individuals. In several studies, adjustment for conditions that developed after pregnancy—such as hypertension, diabetes, or cardiovascular disease—weakened the associations.

Regarding limitations, most data came from retrospective registries, which were susceptible to misclassification of exposure and outcomes, incomplete adjustment for confounders, and undiagnosed kidney disease before pregnancy. Definitions of CKD varied widely, whereas ESKD was more consistently defined, a factor the authors suggested may partly explain the higher relative risk estimates for ESKD.

The review also raised the possibility that preeclampsia functioned less as a direct cause of kidney disease and more as a “stress test” that revealed underlying susceptibility. As the authors noted, “Preeclampsia is increasingly regarded as a stress test, which may unmask an underlying maternal pathology, such as kidney disease.”

The investigators concluded that routine long-term nephrology follow-up for all individuals with a history of preeclampsia may not be warranted in the absence of persistent postpartum abnormalities. They supported closer monitoring during the first year after delivery but cautioned against prolonged surveillance or assumptions of high lifetime kidney risk without additional clinical indicators.

Ultimately, the authors called for well-designed prospective studies with prepregnancy baseline assessments to clarify whether the relationship between preeclampsia and later kidney disease is causal. Until then, they argued, the existing data support vigilance without overmedicalization.

Reference

1. Bianchi G, Vogt B, Bargagli M, Ferrier C. The dilemma of chronic kidney disease and end-stage kidney disease following pre-eclampsia: a literature review and meta-analysis. Int Urol Nephrol. 2025;57(12):4131-4140. doi:10.1007/s11255-025-04591-2

2. FAQs. Preeclampsia Foundation. Accessed January 13, 2026. https://www.preeclampsia.org/faqs