Download Renal Disease in Pregnancy

Renal Disease in Pregnancy
Registrar Teaching November 2014
Dr Sarah Pixton
Talk outline
• 1. Renal embryology- How the renal system
develops
• 2. Physiology in Pregnancy- How the renal system
changes with pregnancy
• 3. CHRONIC
– Overview of How pregnancy effects CRD
– How CRD affects pregnancy
– Specific conditions in CRD
• 4. ACUTE
– Acute renal disease in pregnancy
1. Renal Embryology
A. The Pronephros:
Is the cranialmost set of tubes, which mostly
regress begins 4th week & disappears by day
24 or 25
B. The mesonephros:
Is located along the midsection of the
embryo and develops into mesonephric
tubules and the mesonephric duct (Wolffian
duct).
These tubules carry out some kidney function
at first, but then many of the tubules
regress. However, the mesonephric duct
persists and opens to the cloaca at the tail of
the embryo.
C. The metanephros:
Gives rise to the definitive adult kidney.
Develops from an outgrowth of the caudal
mesonephric duct, the ureteric bud, and
from a condensation of nearby renogenic
intermediate mesoderm, the metanephric
blastema
Renogenesis
Cranial-caudal patterning establishes a “renogenic” region within the intermediate
mesoderm in the tail of the embryo –this renogenic mesoderm is the METANEPHRIC
BLASTEMA
The METANEPHRIC BLASTEMA secretes growth factors that induce growth of the
URETERIC BUD from the caudal portion of the mesonephric duct.
The URETERIC BUD proliferates and responds by secreting growth factors that
stimulates proliferation and then differentiation of the metanephric blastema into
glomeruli and kidney tubules
Ascent of the kidneys and associated
malformations
2. Physiological Changes in Pregnancy
• Blood volume and red cell mass increase by up to 50%, systemic
vascular resistance falls and cardiac output increases by up to 30%.
These cardiovascular adaptations have a profound effect on kidney
• Increase in the GFR and renal plasma flow (30-50% by T2 persist till
term)
• Fall in serum creatinine (by 20-30%)
• Increased protein excretion= 300mg/24hrs upper limit. PCR
30mg/mmol
• Physiological hydronephrosis=
– increase in size of kidney by 1.5cm
– Dilatation of renal pelvis and ureter occurs R>L
Smooth muscle relaxation due to progesterone effect. Gravid uterus
dextrorotation to right
3. Chronic/ Pre existing renal Disease
• CKD is rare in pregnant patients, affecting
0.15% of pregnancies, and most patients have
early stages of CKD.
• In the general population, diabetes mellitus
and hypertension are the commonest causes
of CKD.
Effect of Pregnancy on Chronic Renal
Disease CRD
Renal
Impairment
MILD (Cr
<125)
MOD (Cr
<170)
SEVERE (Cr Cr >220
<220)
Loss of
Function
2%
40%
65%
Postpartum
20%
deterioration
50%
60%
ESRF
33%
40%
2%
75%
• Mod-severe renal impairment = 25-50% accelerated decline in
renal function…
• Most with severe CRD fail to return to pre pregnancy baseline
renal function…
• 1 in 3 women with Cr >180 will require dialysis during pregnancy
or within 6 months post partum..
Previous incidence
• Mild disease: Approximately 16% of the patients showed a decline in renal
function. Most of the latter returned to pre-pregnancy levels of renal
function during the postpartum period; however, 6% progressed to endstage renal disease
A.I. Katz, J.M. Davison, J.P. Hayslett, et al. Pregnancy in women with kidney disease Kidney Int,
18 (1980), p. 192
• Severe disease (Cr >250): seem to be at significant risk for a decline in
function following pregnancy. Jones and Hayslett reported that 4 of 12
progressed to end-stage renal disease within 1 year. Cunningham reported
that 5 of 11 patients (45%) progressed to end-stage renal disease.
D.C. Jones, J.P. Hayslett Outcome of pregnancy in women with moderate or severe renal
insufficiency N Engl J Med, 335 (1996), p. 226
F.G. Cunningham, S.M. Cox, T.W. Harstad, et al. Chronic renal disease and pregnancy outcome
Am J Obstet Gynecol, 163 (1990), p. 453
Effect of CRD on Pregnancy
• Miscarriage
• Gestational Hypertension in 50%
• PET (If mild CRD risk = 20%, if severe cr >180 =
60%)
• IUGR (if severe 65%)
• PTD (if severe 90%)
• LSCS
• Fetal death (with urea >20-25 mmol/l 10%)
Effect CRD on Pregnancy cont..
• Black dots = mild to mod Red dots= severe
Exam /Investigations
Blood pressure;
Hypertension is strongly related to decline of renal function and adverse pregnancy outcomes. Check each visit
Routine antenatal tests;
G&H, rubella, HIV, syphilis, hepatitis B & C, HIV serology, urine m/c/s, pap smear. Regular screen for asymptomatic bacturia
FBC and iron studies;
Baseline assessment of Hb and potential anaemia
Urea and creatinine;
Baseline renal function which allows assessment of pregnancy risk
Calcium and vitamin D;
Assessment of renal bone disease
Spot urine protein creatinine ratio or 24 hour urine protein collection;
Baseline function which allows assessment of pregnancy risk. Do Urinalysis each visit- if pos do PCR.
Consider CT head to exclude intracranial aneurysms for those with FHx or known PCKD
Early and 26-28/40 GTT if on corticosteroid use eg in renal transplant
Management
• Pre pregnancy counselling
essential
• Role of aspirin in prevention
of PET ( see NICE
Guidelines)
• Diagnosing superimposed
PET :
– BP >160/110 sudden
worsening when previous
good control
– >2g proteinuria or rapid
increase in proteinuria
– Cr >110
– +/- additional feature of PET
• Multidisciplinary team
NICE Guidelines 2010
• 1) Assess RF
• 2) Commence Aspirin if:
one HIGH risk factor
OR
>= 2 MODERATE risk
factors
To commence low dose
aspirin (75-100mg/ day)
at 12 weeks
Risk factors for pre-eclampsia:
Moderate:
 First pregnancy
 Age ≥ 40 years
 Pregnancy interval > 10 years
 BMI ≥ 35 kg/m2 at first visit
 Family history of pre-eclampsia
 Multiple pregnancy
High:
 Hypertensive disease during previous pregnancy
 Chronic kidney disease
 Autoimmune disease such as SLE or APLS
 Type 1 or type 2 diabetes
 Chronic hypertension
Specific Conditions
In most cases the renal function
rather than aetiology is what
impacts fetal outcome.
..Except if due to UTI increased
risk PTL, SLE or Diabetes which
can have negative impact on
fetal outcome independent of
renal function.
Glomerulopathies
the kidney esp the glomerulus and its capillaries, is subject to a large number
of acute and chronic diseases,
• There are several distinct clinical glomerulopathic syndromes:
acute nephritic, pulmonary-renal, nephrotic, basement
membrane, glomerulovascular and infectious disease
syndromes.
1) Acute Nephritic Syndrome
Presents with hypertension,
haematuria, red cell casts,
pyuria and proteinuria
In some patients rapidly
progressive glomerulonephritis
leads to end stage renal failure,
in others chronic
glomerulonephritis develops
Systemic Lupus
Erythematosus SLE
•
•
•
•
•
Lupus nephritis often enters a phase
of quiescence during pregnancy as a
result of increased endogenous
corticosteroids
flares can often occur in the
puerperium
If lupus flares do occur during
pregnancy they can be difficult to
distinguish fromPET: HTN, proteinuria
and decline in renal function, often
with thrombocytopaenia.
The presence of invisible haematuria,
depressed serum complement levels,
a rise in anti-double-stranded DNA
titre and cutaneous manifestations of
SLE support a diagnosis of a lupus
flare
IgA Nephropathy
•
also known as Berger
disease
• most common form of
acute glomerulonephritis
worldwide.
• Its primary form is an
immune-complex disease.
Henoch- Schönlein purpura
may be a systemic form of
the disease
2) Nephrotic Syndrome
• Spectrum of renal disorders,
proteinuria is the hallmark
• =Proteinuria >3g/24hr, Serum
albumin <30g/L and oedema
• Defect in the glomerular capillary
wall allowing excessive filtration
of plasma proteins
• When nephrosis
complicates pregnancy, the
maternal and fetal
prognosis depends on the
underlying cause and
severity of the disease.
Where possible a renal
biopsy may indicated to
determine cause.
• Perinatal mortality may be
40% if it develops during T1
PCKD
•
•
•
•
•
•
•
•
Autosomal Dominant
Incidence 1:800 live births
10% ESRF is due to PCKD
85% cases due to mutation
of PKD1 gene on Ch16
15% due to mutation PKD2
on Ch 4.
Usually asymptomatic till
30s or 40s
Hypertension develops in
75%
Progression to renal failure
is a major problem
• Superimposed ARF may
develop from infection or
obstruction from cyst
displacement (kink ureter)
• Other organ involvement
includes liver with 1/3 pt
asymptomatic hepatic cysts
• Increased incidence
cardiovalvular lesions esp
Mitral valve prolapse (13
fold increase)
• Approx 10% die from
ruptured intracranial berry
aneurysms
Acute renal Disease during Pregnancy
• Pyelonephritis=
– Asymptomatic bacturia on screening in T1 should
be treated and MSU repeated.
– Renal tract dilatation and urinary stasis results in
increased rates of pyelonephritis
Acute Renal Injury (AKI)
Avoiding Acute Tubular Necrosis
• 1 Prompt and vigorous replacement of blood in instances of massive
hemorrhage, such as in placental abruption, placenta previa, uterine
rupture, and postpartum uterine atony
• 2. Termination of pregnancies complicated by severe preeclampsia or
eclampsia and careful blood replacement if loss is excessive
• 3. Close observation for early signs of sepsis syndrome and shock in
women with pyelonephritis, septic abortion, chorioamnionitis, or sepsis
from other pelvic infections
• 4. Avoidance of potent diuretics to treat oliguria before initiating
appropriate efforts to ensure that cardiac output is adequate for renal
perfusion
• 5. Avoidance of vasoconstrictors to treat hypotension, unless pathological
vasodilation is unequivocally the cause of the hypotension
References
• Embryology Learning Resources-Duke University Medical School
https://web.duke.edu/anatomy/embryology/urogenital/urogenital.html
• Renal Disease In Pregnancy Curtis L. Sanders, MD, Michael J. Lucas,
MD.Obstetrics and Gynecology Clinics of North America Volume 28, Issue
3, 1 September 2001, Pages 593–600
• Renal Disease in Pregnancy by Nelson-Piercy, Catherine. Journal of Renal
Nursing, ISSN 2041-1448, 07/2012, Volume 4, Issue 4, pp. 168 – 169
• Renal Disease in Pregnancy Matt Hall, Nigel J Brunskill. “The Pink Journal”
Obstetrics, Gynaecology and Reproductive Medicine 20:5 2010
• NICE Guidelines August 2010. Hypertension in pregnancy: The
management of hypertensive disorders during pregnancy
• Williams Obstetrics Chapter 48 Renal and Urinary Tract Disorders