Maternal Kidney Adaptation and Function in Pregnancy: Review and Perspectives.

Pregnancy imposes considerable physiological demands on the maternal kidney, requiring coordinated structural, hemodynamic, and molecular adaptations to maintain homeostasis and support fetal development. This review synthesizes renal changes throughout normal and abnormal gestation, emphasizing the dynamic interactions among maternal, placental, and fetal systems. These adaptations are driven by integrated hormonal pathways, including the renin-angiotensin system and vasodilatory mediators, as well as emerging mechanotransductive processes that enable the kidney to sense and respond to increased flow and pressure. Bidirectional signaling between the placenta and maternal kidney aligns maternal physiology with fetal demand. Dysregulation of these processes leads to complications such as preeclampsia, gestational hypertension, and pregnancy-associated acute kidney injury, with lasting consequences for maternal and offspring health. Key gaps remain in defining kidney and placental interactions, renal immune and mechanosensory roles, and accurate biomarkers of renal function in pregnancy. Advancing research in these areas is critical to improving diagnosis and outcomes in renal and pregnancy-related disorders.