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Kidney health outcomes of hypertensive disorders of pregnancy

Nature Reviews Nephrology volume 21, pages 671–686 (2025)Cite this article

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Abstract

Hypertensive disorders of pregnancy (HDPs), including pre-eclampsia (PE), are frequent, affecting 8–10% and 2–4% of all pregnancies, respectively. Among HDPs, PE is the best characterized and most frequently studied — it is a heterogeneous disease with different clinical phenotypes reflecting distinct underlying mechanisms that ultimately result in widespread endothelial dysfunction and systemic damage. HDP clinical remission is common after delivery, but the long-term health of women with a history of HDP is adversely affected compared with that of women with normotensive pregnancies. The relationship between HDP and kidney health is bidirectional: chronic kidney disease (CKD) increases the risk of HDP, and HDP raises the risk of future CKD. To what extent this increased risk of CKD after HDP is due to pre-existing CKD that is unmasked by pregnancy and/or whether HDP is a causal factor in CKD remains unclear. CKD is diagnosed in up to 20% of women after PE, and the lifetime risk of kidney failure after one episode of PE is 4–8 times higher than that of the general population, increasing further with PE recurrence. These risks are cross generational, as women born prematurely from pregnancies complicated by PE and fetal growth restriction can have low nephron mass, which would not only increase their lifetime risk of CKD but also their risk of developing PE in their own pregnancies.

Key points

  • Hypertension disorders of pregnancy (HDPs) and pre-eclampsia (PE) are frequent pregnancy complications, affecting 8–10% and 2–4% of all pregnancies, respectively. These complications are associated with adverse long-term cardiovascular and kidney outcomes.

  • The relationship between PE and chronic kidney disease (CKD) is bidirectional, as CKD increases the risk of PE and PE is associated with increased risk of CKD later in life. PE might occur in the setting of undiagnosed CKD predating pregnancy or it might contribute to kidney injury and future CKD.

  • The effects of HDP and PE are cross generational, as offspring born prematurely from PE pregnancies frequently have low nephron mass, which, in female offspring, increases the risk of complicated pregnancies in adulthood.

  • A nephrology work-up after an episode of HDP should be considered to assess potential undiagnosed CKD, address risk factors and promote long-term kidney health.

  • No satisfactory preventive strategies or treatments exist for HDP. Further research is needed to better understand the pathogenesis and long-term effects of PE and HDP overall to inform targeted strategies for prevention and care.

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Fig. 1: Global burden of HDPs and demographic and health indicators of global regions.
Fig. 2: Risk factors for CKD and HDPs.
Fig. 3: Pathological processes and risk factors involved in the development of pre-eclampsia.
Fig. 4: Interplay between the placenta, the kidneys and impaired fetal development.

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Author notes

  1. These authors contributed equally: Massimo Torreggiani, Nora Schwotzer.

Authors and Affiliations

  1. Néphrologie et Dialyse, Centre Hospitalier Le Mans, Le Mans, France

    Giorgina Barbara Piccoli & Massimo Torreggiani

  2. Service de Néphrologie et d’Hypertension, Département de Médecine, Centre Hopstialier Universitaire Vaudois and Université de Lausanne, Lausanne, Switzerland

    Nora Schwotzer & Fadi Fakhouri

  3. Nephrology, Department of Medical Science and Public Health, San Michele Hospital, ARNAS G. Brotzu, University of Cagliari, Cagliari, Italy

    Gianfranca Cabiddu

  4. Department of Obstetrics and Gynecology, Nuovo Ospedale degli Infermi, Biella, Italy

    Rossella Attini

  5. Department of Intensive Medical Care, Isidro Espinosa de los Reyes National Perinatology Institute, Mexico City, Mexico

    Alejandra Orozco

  6. Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt

    Rasha Shemies

  7. Pregnancy and Kidney Research Australia, Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital and Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia

    Shilpanjali Jesudason

  8. Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia

    Shilpanjali Jesudason

  9. Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA

    Vesna D. Garovic

Authors
  1. Giorgina Barbara Piccoli
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  2. Massimo Torreggiani
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Contributions

N.S. researched data for the article. N.S., G.C., R.A., A.O., R.S., S.J. and F.F. made substantial contributions to discussions of the content. G.B.P., M.T., F.F. and V.D.G. wrote the manuscript. G.B.P., M.T. and V.D.G. reviewed or edited the manuscript before submission.

Corresponding authors

Correspondence to Giorgina Barbara Piccoli or Vesna D. Garovic.

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Nature Reviews Nephrology thanks Kate Bramham, Titia Lely and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Piccoli, G.B., Torreggiani, M., Schwotzer, N. et al. Kidney health outcomes of hypertensive disorders of pregnancy. Nat Rev Nephrol 21, 671–686 (2025). https://doi.org/10.1038/s41581-025-00977-8

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