Routine UACR Screening Unmasking Reflux Nephropathy after a Pregnancy Complicated by Gestational Diabetes and Preeclampsia
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Abstract
Background: Pregnancy may act as a physiological stress test that unmasks underlying renal and cardiometabolic disease. Persistent hypertension and proteinuria after a pregnancy complicated by preeclampsia should prompt evaluation for chronic kidney disease rather than being attributed solely to prior obstetric complications.
Case presentation: We report the case of a 34-year-old woman with a history of two miscarriages who subsequently conceived and delivered a healthy child after a complicated pregnancy marked by gestational diabetes mellitus, preeclampsia, proteinuria, and recurrent urinary tract infections. One year postpartum, her gestational diabetes had resolved; however, hypertension persisted. Routine urinary albumin-creatinine ratio testing revealed severe albuminuria, with UACR of approximately 2120 mg/g creatinine. Further evaluation confirmed significant sub-nephrotic range proteinuria, with 24-hours urinary protein excretion of 2575 mg/day. Urine culture grew multidrug-resistant Klebsiella species at 10⁵ CFU/mL, sensitive to fosfomycin. She was treated with oral fosfomycin 3 g for four cycles, following which repeat urine culture became sterile. Imaging evaluation suggested reflux nephropathy, with DMSA scan showing relatively preserved split renal function of 48:52.
Conclusion: This case highlights the importance of postpartum renal surveillance in women with preeclampsia, gestational diabetes, recurrent urinary tract infection, and persistent hypertension. Severe albuminuria in such patients may reveal occult reflux nephropathy despite preserved renal function. Early recognition allows timely nephrology and urology referral, culture-guided treatment of infection, blood pressure optimization, and long-term cardiometabolic risk reduction.
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