Renal disease Flashcards

1
Q

renal physiology in pregnancy

A

Renal blood flow and GFR increase by 80%

  • -> increased urinary frequency
  • -> increased CrCl and lower serum Cr
  • -> increased protein and glucose in urine

Renal hydronephrosis (R>L, up to 15-20mm on right) - progesterone = smooth muscle relaxation, compression from gravid uterus

Urinary stasis –> predisposed to UTI

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2
Q

Asymptomatic bacteriuria

A

Occurs in 2-5% of pregnant women
A/w pyelo (30%), PTL

UTI treatment 3-7 days

Recurrent UTI x3 confirmed with MSU (or pyelo) then prophylaxis and consider renal USS

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3
Q

Pyelonephritis

A

2% of pregnancies
E. coli - leading cause (other Klebsiella, Proteus and Enterobacter organisms)

Risks:

  • PTB
  • Recurrence (20%)
Rx: analgesia, IVF
cefuroxime 
Avoid gent (fetal ototoxicity)
VTE prophylaxis
IDC and fluid balance (if septic)
Prophylaxis, monthly MSU
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4
Q

Renal stones diagnosis and management

A

No increased risk of forming stones in pregnancy

USS - will identify 50%
Consider MRI

Conservative
- Successful in 70%
- IVF, analgesia, antibiotics
Nephrostomy if evidence of obstruction on imaging

Long-term management - insertion of JJ stents
Lithotripsy contraindicated in pregnancy

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5
Q

CKD pre-pregnancy counselling

A
MDT approach
Optimise BP and diabetes
- Poor control a/w worse prognosis
Baseline urea, creatinine and PCR
FBC
- Assess for anaemia of chronic disease
- Booking bloods and serology as immunocompromised (CMV, TORCH)
Stabilise disease on low doses of medication
Folic acid 5mg
Lifestyle advice
Consider genetic counselling for inherited conditions
Aspirin and calcium when pregnant
Progesterone pregnancy
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6
Q

Common renal meds safe in pregnancy

A

Tacrolimus
- Check levels each trimester

Cyclosporin

  • Check levels each trimester
  • Increased risk of GDM

Prednisone

  • Increased risk of GDM
  • Fetus exposed to 10% of maternal dose
  • IV hydrocortisone in labour

Azathioprine
- Increased risk of IUGR and PTL

Labetalol
Nifedipine
Clexane

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7
Q

Renal meds contraindicated in pregnancy

A

Mycophenolate - Increased risk of miscarriage and congenital defects, Switch >3/12 pre-pregnancy to azathioprine
Methotrexate
Cyclophosphamide (teratogenic)
Rituximib (neonatal B cell depletion)
ACE-inhibitors - Fetal renal failure, oligohydramnios, pulmonary hypoplasia

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8
Q

Risk of pregnancy on renal function

A

Creatinine <125

  • Good outcomes
  • 2% will have worsening function, does not persist PP

Creatinine 125-180

  • 40% worsening function
  • 20% persist PP
  • 2% progress to ESRF

Creatinine >180

  • 50% worsening renal function PP
  • 35% progress to ESRF
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9
Q

Risks of renal disease on pregnancy

A

PET, IUGR

  • 25% with mild (Cr <125)
  • 60% with Cr >180

PTB

  • 30% with mild
  • 90% with severe (Cr >180)

C-section (3x increased)
Anaemia
Vitamin D deficiency

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10
Q

Implications of dialysis on pregnancy

A

50% perinatal mortality rate
Fertility reduced
Chance of successful pregnancy <50%
High urea = risk of polyhydramnios and fetal death
- Increase dialysis duration to control urea, aim for <15

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11
Q

Implications of renal transplant on pregnancy

A

> 2y after transplant for conception
Should be stable on medications for 1-2y prior to conception
Successful pregnancy outcomes for 95% who reach second trimester
Prognosis related to graft function at conception
No adverse effects on graft survival if Cr <100
- Cr >130 - 65% graft survival at 3y
Chance of graft rejection during pregnancy = 2%
Vaginal birth preferred mode of delivery
- Higher rates of CS than general population
- If CS then risk of 1-2% injury to transplanted kidney or ureter
Immunocompromised, therefore IV antibiotics for any surgical procedure (including episiotomy)

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12
Q

Antenatal management of CKD

A
MDT
Meds:
	- Supplement folic acid and vitamin D
	- Low dose aspirin and calcium
Bloods baseline:
	- FBC for anaemia
	- PET screen 
VTE risk assessment
	- Nephrotic range proteinuria --> clexane
Control BP 
Monitor for PET regularly 
	- Difficult to distinguish between PET and worsening renal function, therefore consider placental growth factor blood test
Monitor renal function (with Cr not eGFR)
Serial growth scans
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13
Q

What is a phaeochromocytoma

A
Catecholamine-secreting tumours 
Adrenal medulla (90%) 
Along the sympathetic chain (paragangliomas)

Clinical features

  • Palpitations, sweating, anxiety
  • Glucose intolerance
  • Headache
  • Labile HTN

Sudden attacks

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14
Q

Diagnosis of phaeochromocytoma

A
Elevated urine (24h collection) or plasma catecholamine 
Localisation of the tumour - USS and MRI
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15
Q

Effect of phaeochromocytoma on pregnancy

A

High risk of hypertensive crisis and maternal death (up to 15%)
- Can be precipitated by labour, vaginal or CS delivery, opiates
High fetal mortality (30%)

Main causes of death - cardiac arrhythmia, cerebrovascular disease, pulmonary oedema

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16
Q

Management of phaeochromocytoma

A

Alpha-blockade, e.g. phenoxybenzamine, to control HTN
Once adequately alpha blocked, introduce beta blocker to control tachycardia
Serial USS (because risk of FGR with beta blocker)
Planned CS recommended
- Increased risk of maternal deaths during labour
Surgery before 24/40 for tumour removal
- After 24/40 delay until fetal maturity
- Or delay until PP
- Need 3 days of adequate beta blockage before OT

17
Q

What is conn’s syndrome? and how does it present

A

Primary hyperaldosteronism secondary to adrenal adenoma, hyperplasia or malignancy

HTN
Hypokalaemia
Metabolic acidosis

Aldosterone - essential for sodium conservation

18
Q

Diagnosis of Conn’s syndrome

A

Difficult in pregnancy as aldosterone levels naturally increase
Traditional diagnostic test: raised aldosterone : renin ratio
Adrenal USS or MRI

19
Q

Management of Conn’s syndrome

A
Case reports suggest defer surgery until PN 
- Unless malignancy suspected 
Medical management 
- Antihypertensives
- Potassium supplements
- Potassium-sparing diuretics 

Avoid:
- Spironolactone - Under-virilisation of male fetus

20
Q

Implications of polycystic kidney disease on pregnancy

A

Risks in pregnancy:

  • PET
  • UTIs

Bleeding into renal cyst –> loin pain, haematuria
Pregnancy has no adverse long-term effect on renal function
May be associated with:
- Polycystic liver disease - May enlarge during pregnancy
- Subarachnoid haemorrhage from intracranial aneurysms