Download - Pakistan Society of Nephrology

Pregnancy
& Kidney
Prof. (Dr.) Iffat Yazdani
Aga Khan University Hospital /
Clifton Kidney & General Hospital
Normal Renal Alterations in Pregnancy
Changes in G.F.R.
• GFR and RBF rise markedly
• Glomerular hyperfiltration results in normal reduction
in the plasma creatinine concentration to about 0.4 to
0.5 mg/dL
• Blood urea nitrogen (BUN) and uric acid levels fall for
the same reason
Before Pregnancy
Women with chronic kidney
disease often have amenorrhoea
but may still occasionally ovulate
and thus conceive
• Contraceptive measures that consider clinical comorbidities should be
taken by those who do not wish to become pregnant.
• Folic acid 400 μg, until 12 weeks’ gestation.
• Low dose aspirin (50-150 mg/day) reduces the risk of pre-eclampsia
• Fetotoxic drugs - such as ACE inhibitors and angiotensin II receptor
blockers—should be stopped.
2 questions, when a woman with
underlying kidney disease
becomes pregnant:
• What is the effect of pregnancy
on the kidney disease ?
• What is the effect of the kidney
disease on pregnancy ?
1. Pregnancy in mild to moderate Kidney
Disease
2. Pregnancy in Dialysis Patients
3. Pregnancy in Renal Transplant
4. Pregnancy in Diabetic Nephropathy
5. Pregnancy in Lupus Nephropathy
6. Pregnancy in Glomerulonephritis
Renal Function may decline as a result of
Pregnancy among patients with renal
disease, determined in part by the
severity of underlying renal disease.
Effect of Pregnancy on
Renal Function
GRF Mildly reduced
Plasma Creatinine < 1.5 mg %
Permanent decline in Renal
Function 0-10%
Others Transient Decline
GFR moderately reduced
Plasma Creatinine 1.6-2.9 mg % SCreatinine rises as
pregnancy progresses
40% of women decline in
renal function
Risk of Irreversible loss of GRF exceed s in
patients who have uncontrolled hypertension
During Pregnancy
Care of Women with Chronic Kidney
Disease
Urine
4 – 6 Weeks
Check
(1) Prophylactic
antibiotics, (2)
proteinuria –
thromboprophylaxis
with low molecular
weight heparin if >
1g proteinuria /24 h
(3) haematuria –
perform microscopy
Blood
Pressure
Aim to keep
it between
120/70 &
140/90 mm
Hg
Renal Function
Full Blood
Count
Check serum
Keep
creatinine & Urea
Haemoglobin
depending on the
at 10-11 g/l
stage of the disease.
More frequently for
disease stages 3-5
and in the second half
of pregnancy.
Ultrasound of
Renal Tract
Perform Base
line renal
ultrasound –
12 weeks
CKD in mild to moderate kidney
disease
Nevis IF American Society of Nephrology - 2011
– Mother
• Gestational HTN
• Pre Eclampisa / Eclampsia (2nd trimester)
– Child
• Preterm Birth
• Small for age
• Still birth
Frequency of conception
among women of
childbearing age on dialysis
ranges from 0.3 - 1.5 % per
year.
Management of Pregnant Dialysis Patient
• Intensification of dialysis
Keep B.U.N. ↓ 50 mg/dl to avoid polyhydramnios.
5 to 7, Hemodialysis
sessions with
slow rate U.F.
minimal heparinization
bicarbonate buffer
hypotension
to avoid
volume contraction
• Adequate supply of calories and protein
Protein intake should be
- 1 g/kg per day
- Additional 20 g/day for fetal growth.
- Supplemented with water soluble vitamins and zinc
• Antihypertensive regimen
Acceptable antihypertensives include labetalol, Nifedipine XL, methyldopa, and metoprolol.
Avoidable antihypertensives Diuretics, ACE inhibitors, ARBs.
• Correction of Anemia
Give Erythropoietin with Iron & Folic Acid supplemented. Keep Hb % > 10.
• Treatment of premature labor
The use of β agonists is preferred & NSAIDs should be avoided.
• Avoidance of metabolic acidosis
• Prevention of hypocalcemia
• Reinforced fetal monitoring as soon as viability is reached
Common Themes in Dialysing
Pregnant Patients
1. Keeping BUN < 50
2. Increasing dialysis time and frequency
3. BP control
4. Managing anemia with increasing doses of ESA
5. Fetal monitoring once viability reached
Women who Start Dialysis During
Pregnancy
• Likelihood of infant surviving is good
• Termination of a pregnancy after renal function has
begun to deteriorate rarely rescues the kidneys
• NEJM, Jones and Hayslett, 1996, looked at 82
pregnancies in 67 women w/CRI, only 15% of those
w/deteriorating renal function had a return of renal
function to baseline in 6 mths post partum
Medications
Common
medications in
CKD/ESRD
1. Erythropoietin
Safety issues
Comments
Safe to use
Limited data.
2. Iron
Safe to use
Low dose
intravenous iron
recommended
3. Vitamin D
Widely used
Limited data.
4. Heparin
Safe to use
Minimize dose of
heparin
Renal Transplant & Pregnancy
Women are advised to wait at least one year
after living, related-donor transplantation and
two years after deceased transplantation to
avoid complications.
The renal allograft should be functioning well,
with a stable serum creatinine level
<1.5 mg/dL (132 micromol/L) and urinary
protein excretion <500 mg/day.
Common Medications in
Kidney Transplantation
1. Prednisone
Safe to use
Fetal adrenal insuffi
ciency
2. Cyclosporine
Safe to use
IUGR
3. Tacrolimus
Not safe to use
Severe IUGR, renal failure,
hyperkalemia
4.Mycophenolate
mofetil
Not safe to use
Teratogenic in animals
5. Azathioprine
Widely used
Fetal neutropenia,
teratogenic in high doses
6. Polyclonal
antibodies
Not safe to use
Very limited data
C.K.D. and Pregnancy –
Diabetic Nephropathy
• 6% of pregnant women with type I DM have :
– overt diabetic nephropathy (<20/40: U prot>300mg/d
– macroalbuminuria >300mg/d
– alb/creat. ratio >0.3mg/mg)
• Effect of nephropathy on pregnancy
– prematurity(22%)
– IUGR(15%), pre-eclampsia
Pregnant women with diabetes
& risk of developing kidney
diseases
With normal albumin
With microalbuminuria and
normal kidney function
With poorly controlled HTN or
reduced G.F.R. and S.Cr. >
1.5 mg/dL, proteinuria >3 g in 24
hours)
↓ low risk
↓ low risk
↑ high risk
Maternal Complications in
Pregnancies Complicated by Diabetic
Nephropathy (2001 to 2012)
Ekbom P, Damm (Diabetes Care 2001) /Young EC, Pires ML / Carr DB, Koontz GL, Gardella
C. Am J Hypertens / Yogev Y, Chen R, Ben-Haroush (Neonatal Med 2010; 23:999) /
Nielsen LR, Damm P, Mathiesen ER. (Diabetes Care 2009; 32:38)
• Pregnant women with diabetes,
microalbuminuria, and normal kidney function
appear to be at low risk for loss of kidney
function, but may have a transient increase in
albuminuria
• Women with poorly controlled hypertension or
reduced glomerular filtration rate (GFR) and
increased proteinuria (serum creatinine level
>1.5 mg/dL, proteinuria >3 g in 24 hours) at
the onset of pregnancy are at risk of
permanent kidney damage, including endstage kidney disease.
• Recommended B.P. 110-129/ 65-79 mm Hg
Diabetic Kidney Disease
Complications
• Fetal growth restriction
• Abnormal antenatal fetal assessment
• Preeclampsia, even in women with good
glycemic control.
The occurrence of these pregnancy
complications may necessitate preterm delivery
and increases the chance of cesarean birth
C.K.D. and Pregnancy - Lupus
• Rate of relapse not different between pregnant
women and concurrent controls (9-60%).
• Major factor determining a pregnancy related
exacerbation is the stability of the disease before
conception
• If in remission for > 6 months pre-conception, low
incidence of clinical flare during pregnancy.
• Women with intracranial aneurysms may be at
increased risk of subarachnoid hemorrhage
during labor.
Lupus Flare-up Versus Preeclampsia
SLE
+
+
PE
+
+
RBCs cast
+
-
Azotemia
Low C3, C4
+
+
-
+
+/-
Low platelet count
+
+/-
Low leukocyte count
+
-
Proteinuria
Hypertension
Abnormal liver function
test results
Causes of Proteinuria in Pregnancy
Primary renal diseases
•
•
•
•
•
•
•
IgA nephropathy
Minimal change disease
Membranous nephropathy
Focal segmental glomerulosclerosis
Primary glomerulonephritis
Allergic interstitial nephritis
Polycystic kidney disease
Systemic causes
•
•
•
•
•
•
•
•
•
•
Preeclampsia
Diabetic nephropathy
Lupus nephritis (diffuse proliferative, focal proliferative, membranous)
Hypertensive nephrosclerosis
Thrombotic thrombocytopenic purpura (TTP)
Infection-associated glomerular disease (eg, HIV, hepatitis B/C)
Systemic vasculitis
Multiple myeloma
Chronic vesicoureteral reflux
Antiphospholipid syndrome
• Preeclampsia is the most common cause of
proteinuria in pregnancy and must be
excluded in all women with proteinuria first
identified after 20 weeks of gestation.
• If preeclampsia is excluded, then the
presence of primary or secondary renal
disease should be considered.
Criteria for the diagnosis of preeclampsia
Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at
least four hours apart after 20 weeks of gestation in a previously normotensive patient
If systolic blood pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg, confirmation
within minutes is sufficient
and
Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL) ratio
≥0.3
Dipstick 1+ if a quantitative measurement is unavailable
In patients with new-onset hypertension without proteinuria, the new onset of any of the following
is diagnostic of preeclampsia:
Platelet count <100,000/microliter
Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease
Liver transaminases at least twice the normal concentrations
Pulmonary edema
Cerebral or visual symptoms
Adapted from: Hypertension in pregnancy: Report of the American
College of Obstetricians and Gynecologists' Task Force on Hypertension in
Pregnancy. Obstet Gynecol 2013; 122:1122.
Graphic 79977 Version 9.0
Women with Nephrotic Syndrome
• Discomfort from severe leg edema can be managed with
sodium restriction (1.5 g, approximately 60 mEq), bedrest,
and leg elevation.
• Prophylactic anticoagulation is reasonable in pregnant
women with nephrotic syndrome and severe
hypoalbuminemia (serum albumin <2.0 mg/dL, or
<2.8mg/dL in membranous nephropathy), especially if
another risk factor (eg, bedrest) is present.
• Bile acid sequestrants and fibrates can be safely used in
pregnancy to treat severe hyperlipidemia due to nephrotic
syndrome; statins should be avoided.
Kidney Biopsy During Pregnancy
• There are few Indications for Kidney Biopsy s
• May be performed if there is a sudden
unexplained deterioration in renal function or
markedly symptomatic nephrotic syndrome
occurring before 32 weeks gestation.
• Biopsy after week 32 is not recommended.
The Treatment for Pregnancy
Associated AKI
• Preeclampsia-associated AKI is an indication for
delivery. Delivery generally results in completely
recovery of renal function, although moderately
increased albuminuria may persist.
• TTP-HUS-associated AKI is primarily treated with
plasma exchange.
• AFLP-associated AKI includes the treatment of
disseminated intravascular coagulation (DIC) and
delivery of the fetus.
Hypertension
• In women with chronic primary or secondary
hypertension or previous pregnancy-related
hypertension, low-dose aspirin from the
12th week of gestation until delivery is
suggested, but should be determined on a
case-by-case basis.
Thank
You