Renal Flashcards
What is the definition of AKI in pregnancy
- Cr >80
- Cr increase >50% of baseline
Discuss chronic kidney disease in pregnancy
-Causes
-Stages
-Two main indicators of impact of CKD to fertility and pregnancy
- Causes of CKD
-CKD can be caused by many conditions which lead to varying degrees of renal impairment
-reflux nephropathy, diabetic nephropathy, chronic glomerular nephritis, SLE, polycystic kidney disease, IgA nephropathy, sleroderma - Stages of CKD
-5 stages
-Based on eGFR - Two main indicators for pregnancy outcomes irrespective of cause of CKD
- Degree of renal impairment
-Presence of absence of HTN
Discuss the impact of pregnancy on CKD in terms of renal function
-Mild renal impairment
-Moderate renal impairment
-Severe renal impairment
- Mild renal impairment Cr <125
-2% risk of loss of renal function in pregnancy
-Always reversible - Moderate impairment Cr 125-180
-40% loss of function in pregnancy
-2% risk of ESRF - Severe impairment Cr>180
-70% loss of renal function in pregnancy
-35% risk of ESRF
Discus the impact to CKD from pregnancy (4)
- Escalation in hypertension
- Worsening proteinuria
- Increased risk of flare / relapse of glomerulonephritis
- Deterioration in anaemia
Discuss the effect of CKD on pregnancy
-Maternal (5)
-Fetal (4)
- Maternal
-Miscarriage
-PET (RR 10)
-VTE in nephrotic syndrome
-Placental abruption
-Increased risk of CS - Fetal
-FGR (RR 5)
-Preterm delivery - CKD 3-5 = 60-90% risk
-Perinatal mortality
-IUFD - associated with maternal urea levels >20-25 and polyhydramnios
Discuss fetal outcomes for women with CKD for different levels of renal impairment
-Mild impairment Cr <125
-Moderate impairment Cr 125-180
-Severe impairment Cr >180
-On dialysis
- Mild impairment
- PET 22%
-FGR 25%
-PTB 30%
-Perinatal mortality 1% - Moderate impairment
-PET 40%
-FGR 40%
-PTB - 60%
-Perinatal mortality 5% - Severe impairment
-PET 60%
-FGR 65%
-PTB 90%
-Perinatal mortality 10% - On dialysis
-PET 75%
-FGR >90%
-PTB >90%
-Perinatal mortality 50%
Discuss preconception management of CKD
- Counsel regarding risks
-To renal function
-For poor fetal outcomes
-Avoid pregnancy if CKD 4-5 or on dialysis, severe HTN, nephrotic syndrome, active lupus, diabetic nephropathy with Cr >125
-Assess baseline Cr, LFTs, Renal function, PCR
-Optimise BP control. If long standing HTN consider echo
-If on cytotoxic drugs for lupus - stop 3 months before pregnancy
-Stop ACEi and statins
-High dose folic acid
-Low dose aspirin + calcium supplements
Discuss antenatal management for women with CKD (13)
- MDT management
- Low dose aspirin, calcium, vit D, high dose folic acid
- LMWH if proteinuria >3g/day
- Baseline BP, Renal function
- Monitor BP, renal function, albumin, Hb, platelets, proteinuria, urea
- Consider baseline renal USS
- Maternal review fortnightly till 28/40 then weekly
- BP and urinalysis at every visit
- Consider dialysis if urea >17. Linked to IUFD
- Fetal uterine artery dopplers at 24/40
- Fetal growth scans - growth, polyhydramnios
- Manage anaemia - Fe or EPO
- If nephrotic syndrome with oedema consider loop diuretics
Discuss intrapartum and postpartum management in women with CKD
-Intrapartum (3)
-Postpartum (5)
- Intrapartum
-Fluid balance and BP monitoring
-Timing of delivery should be individualised. Increased risk of CS and PTD
-Continuous fetal monitoring - Postpartum
-Monitor BP and fluid balance
-LMWH as increased VTE risk, consider if required for 6/52
-Avoid NSAID
-Reassess renal function
-Resume pre-pregnancy meds. ACEi OK in breastfeeding
Discuss differentiation of PET and deteriorating renal disease
-Shared features (4)
-Features for a renal flare
-Features for PET (3)
- Shared features
-HTN, proteinuria, thrombocytopenia, renal impairment - Features for renal flare
-Development of proteinuria before third trimester
-Presence of haematuria or renal casts
-Active disease within 6 months of concepion
-Raised dsDNA or reduced compliment levels
-Other SLE sx - discoid rash, fatigue, arthralgia - PET features
-No baseline proteinuria
-Elevated or deranged LFTs
-Antithrombin deficiency
Discuss renal biopsy in pregnancy for renal impairment
-Why should it be done (3)
-When should it be done (3)
- Why should it be done
-Only definitive investigation to distinguish between renal flare and PET
-Allows for initiation of immunosuppression if <24weeks
-Allows for knowledge of whether delivery will improve outcomes if >24 weeks - When should it be done
-Non intra-renal causes excluded (PET, obstruction, Infection)
-Pre-existing undiagnosed nephrotic syndrome
-New onset nephrotic syndrome 16-20 weeks
Discuss glomerulonephritis in pregnancy
-Causes
-Impact on pregnancy
-Impact of pregnancy to renal function
-Impact of pregnancy to BP
- Causes of glomerulonephritis
-Post infection (post strep)
-Autoimmune - lupus, Goodpastures, IgA nephropathy
-Vasculitis - polyarteritis - Impact on pregnancy
-Depends on level of renal function and BP control - Impact of pregnancy on renal function
-If renal function normal at conception then little impact
-10% reversible worsening of renal function
-3% progressive worsening of renal function - Impact of pregnancy on BP
-25% reversible worsening of BP
->10% permanent worsening of BP
Discuss reflux nephropathy
-Pathophysiology (4)
-Complications in pregnancy (4)
-Management in pregnancy (3)
- Pathophysiology
-Distinct familial component
-Caused by scarring due to veiscoureteric reflux.
-Leads to progressive renal impairment and ESRD
-Often seen in those with recurrent UTIs, proteinuria, HTN - Complications in pregnancy
-Associated with degree of HTN and baseline renal impairment
-Particularly associated with FGR
-Fetal loss of 18% with Cr >110
-Increased risk of fetal hydroureter and hydronephrosis as genetic - Management in pregnancy
-Consider low dose UTI suppression meds
-Screen for UTI regularly
-Post natal screening of infant
Discuss management of diabetic nephropathy in pregnancy
-Diagnostic criteria (1)
-Impact on pregnancy (8)
-Impact of pregnancy on nephropathy (1)
- Diagnostic criteria
->500mg/day proteinuria where infection has been ruled out - Impact on pregnancy
-Adverse outcomes are doubled in diabetic women with nephropathy compared to those diabetic women without nephropathy
-PET, IUGR, Fetal loss, abruption, PTB
-Increased anaemia
-Increased risk of pulmonary oedema and thrombosis given high risk of nephrotic syndrome - Impact of pregnancy on nephropathy
-Difficult to tell but overall probably no impact
Discuss lupus nephritis in pregnancy
-Pathophysiology (1)
-Diagnosis (2)
-Effect of lupus nephritis on pregnancy (3)
-Effect of pregnancy on lupus nephritis (4)
- Pathophysiology
-50% of patients with Lupus develop lupus nephritis secondary to deposition of immune complexes and complement activation - Diagnosis
-Casts in urine, haematuria, proteinuria
-Definitive dx by renal biopsy - Effect of lupus nephritis on pregnancy
-Acute renal failure and maternal mortality
-PET - increased risk if HTN and presence of antiphospholid antibodies
-Risk of neonatal lupus - Effect of pregnancy on lupus nephritis
-33% have renal flares
-Flares increased in risk if conception at time of active flare (60%)
-21% renal deterioration.
-7% permanent renal deterioration