renal disease in pregnancy

Question 1

Organisms that cause urinary infections are

Answer 1

90 percent of Escherichia coli strains that
cause nonobstructive pyelonephritis have adhesins such as P- and S-fimbriae. These are cell-surface protein structures that enhance bacterial adherence and, thereby, virulence.

Question 2

Asymptomatic Bacteriuria

Answer 2

A clean-voided specimen containing more than 100,000 organisms/mL is diagnostic. It may be prudent to treat when lower concentrations are identified,
because pyelonephritis develops in some women despite colony counts of only 20,000 to 50,000 organisms/mL.

Question 3

urinary tract infection to be associated with greater risks for

Answer 3

low-birthweight infants, preterm delivery, pregnancy-associated hypertension, and anemia.

Question 4

Asymptomatic Bacteriuria Treatment

Answer 4

empirical oral treatment for 10 days with nitrofurantoin macrocrystals, 100 mg at bedtime.
Satisfactory results are also achieved with a 7-day oral course of nitrofurantoin,100 mg given twice daily.
For recurrent bacteriuria, success achieved with nitrofurantoin, 100 mg orally at bedtime for 21 days.

Question 5

Lower urinary tract symptoms with pyuria accompanied by a sterile urine culture may stem from urethritis caused by

Answer 5

Chlamydia trachomatis. Mucopurulent

cervicitis usually coexists, and azithromycin therapy is effective

Question 6

The differential diagnosis of acute pyelonephritis includes

Answer 6

labor, chorioamnionitis, adnexal torsion, appendicitis, placental abruption, or infarcted leiomyoma.

Question 7

Acute pyelonephritis most common isolated organisms:

Answer 7

Bacteremia is demonstrated in 15 to 20 percent of these women. E coli is isolated from urine or blood in 70 to 80 percent of infections, K.pneumoniae in 3 to 5 percent, Enterobacter or Proteus species in 3 to 5 percent, and gram-positive organisms, including GBS and Staphylococcus aureus, in up to 10 percent of cases

Question 8

management of acute pyelonephritis:

Answer 8

Hospitalize patient
Obtain urine and possibly blood cultures
Evaluate hemogram, serum creatinine, and electrolytes
Monitor vital signs frequently, including urinary output—consider indwelling catheter
Establish urinary output ≥50 mL/hr with intravenous crystalloid solution
(Intravenous hydration to ensure adequate urinary output is the cornerstone of treatment)
Administer intravenous antimicrobial therapy empirical, and ampicillin plus gentamicin; cefazolin or ceftriaxone; or an extended-spectrum antibiotic are all 95-percent effective in randomized trials
Obtain chest x-ray if there is dyspnea or tachypnea
Repeat hematology and chemistry studies in 48 hours
Change to oral antimicrobials when afebrile
Discharge when afebrile 24 hours, consider antimicrobial therapy for 7 to 10 days
Repeat urine culture 1 to 2 weeks after antimicrobial therapy completed

Question 9

most stones in pregnancy—65 to 75 percent—are (The type)

Answer 9

Calcium salts make up approximately 90 percent of stones, and hyperparathyroidism should be excluded. Although calcium oxalate stones in young nonpregnant women are most common, most stones in pregnancy—65 to 75 percent—are calcium phosphate or hydroxyapatite

Question 10

When Hydronephrosis and hydroureter return to normal after pregnancy?

Answer 10

3-4 months after delivery

Question 11

What are the renal filtration physiological changes?

Answer 11

Renal plasma flow increase by 50-80%. GFR increase by 40-50%.
Creatinine clearance increase.
Lower mean BUN and creatinine.

Question 12

What is the abnormal level of protein in urine?

Answer 12

Protein /creatinine ration more or equal to 0.3 mg/dL. Protienurea more than 300 mg/dL.

Question 13

When you should consider prophylaxis antibiotics in cases of UTI?

Answer 13

If recurrent UTI 2 or more.

Question 14

Does women with sickle cell trait have increased risk of asymptomatic bacteriuria (ASB)?

Answer 14

Yes , 2 folds , should. Be screened every trimester.

Question 15

What are the first line antibiotics?

Answer 15

Nitrofunitoin and Slufonamides. Starting from the 2nd trimester.

Question 16

Whats the causative organisms for urethritis?

Answer 16

Chlamydia trichromatis.

Question 17

If the patient has symptoms of acute cystitis with negative urine culture what will you suspect?

Answer 17

Urethritis

Question 18

Q: Whats the treatment of urethritis?

Answer 18

Single dose of aZithromycin in for the patient and her partner.

Question 19

Q: Whats the leading cause of septic shock in pregnancy?

Answer 19

Pyelponephritis

Question 20

What is the antibiotics of choice in pyelonephritis?

Answer 20

Ceftriaxone.
Gentamicin and ampicillin.
If the patient is penicllin allergy:
Clindamycin and gentamicin.

Question 21

What are the complications of poly cystic kidney disease?

Answer 21

Hypertensive crisis
pre eclampsia.
Recurrent UTI Flank pain Nephrolithiasis Hematuria.

Question 22

Whats the definitive diagnosis for glomerular disease?

Answer 22

Renal biopsy

Question 23

How does nephritis syndrome presents?

Answer 23

Hypertension 
Hematuria
Urinary red cell casts
Pyuria.
Protienurea.

Question 24

What are the causes of nephritic syndrome?

Answer 24

Poststreptocoocal golmerluonephritis .
Lupus nephritis.
Immunoglobulin A nephropathy.
Membrane proliferation glomerulonephritis Endocarditis associated glomerulonephrtisi Antiglomerular basemenet memebrance disease Goodpasture syndrome
Wagner syndrome Chug-strausss syndrome.

Question 25

What does nephrotic syndrome presents as?

Answer 25

Protienurea > 3.5 g/dL. Hypertension
Edema
Hyperlinked is
Minimal hematuria. Minimal cells or casts.

Question 26

What are the causes of nephrotic syndrome?

Answer 26

Minimal change disease
Focal segmental gllyomloscelerosis secondary to HIV Membranous glumorluonephririts
Diabetic nephropathy
Hep B
SLE
Amylodosis.

Question 27

What are the complications of nephrotic syndrome on pregnancy ?

Answer 27

Preterm labor
IUGR
Still birth
Maternal hypertension Pet
Impaired renal function

Question 28

What are the criteria to diagnose Acute kidney injury?

Answer 28

Increase in serum creatinine by > or equal to 0.3 mg/dL ( 27 micromol/L) in 48 hours. Or Increase more than or equal to 1.5 times baseline within 7 days.
Or decrease in urine volume to < than 3 ml/kg over 6 hours.

Question 29

What are the causes of acute kidney injury ?

Answer 29

In early pregnancy&raquo_space; hyperemesis gravidarum , septic abortion
Later in pregnancy or postpartum&raquo_space; viral or bacterial infection , severe PET , Hemolytic uremic syndrome ( HUS ) , TTP , AFLP , pyelonephroitis , ureteral compression or injury , obstetrical hemorraghe .

Question 30

Whats the management of AKI?

Answer 30

Fluid resussutiation
Avoid nephrotoxic medications
Manage complications such as hyperkalemia Timely initiation of renal replacement therapy.

Question 31

What are the indications for dialysis?

Answer 31

BUN > 50 because BUN is fetotoxic.

Question 32

How to differentiate between HUS/TTP from pre-eclampsia?

Answer 32

Presence of shicstocytes on peripheral blood smear .

Question 33

Whats the mainstay of treatment of HUS?

Answer 33

Plasmapharesis and eculizumab.

Question 34

How to diagnose CKD?

Answer 34

Impaired renal function or damage for more than 3 months.

Question 35

What are the categories of CKD?

Answer 35

Mild ( serum creative less than 1.5 mg/dL)
Moderate ( 1.5-3.0 mg/dL )
Severe ( > 3.0 mg/dL)

Question 36

what is the antepartum management in cases of CKD?

Answer 36

• Early pregnancy diagnosis and dating
• Preconception planning and counseling are encouraged.
• Baseline laboratory studies including serum creatinine, electrolytes, BUN, 24-hour urine protein and creatinine clearance, urinalysis, and urine culture; serial monitoring of maternal renal function, as clinically indicated
• Increased frequency of prenatal visits, depending on disease severity
• Serial ultrasonographic fetal growth examinations.
• Antepartum fetal testing in the third trimester.

Question 37

What is the conception rate of patient on dialysis ?

Answer 37

1%.

Question 38

whats the percentage of surviving infants as outcome ?

Answer 38

40-75%.

Question 39

fertility rate after renal transplant?

Answer 39

5-10%.

Question 40

Q: When can a women get pregnancy after transplant ?

Answer 40

1 year if transplant from a living related donor. 2 years after deceased donor transplant.

Question 41

What are the factors associate with favorable outcomes of pregnancy of mother with renal transplant?

Answer 41

Creatinine less than 1.5 mg/dL.
Well controlled blood pressure.
Protienurea less than 500 mg/day.
No recent episode of acute rejection.
Maintenance level of immunisuppresion.
Normal apppearing of transplanted kidney on ultrasound.

Question 42

What are the commonly used immunosuppressive used in pregnancy ?

Answer 42

Cyclosporine
Tacrolimus
both needs to be monitored and follow up of renal function.

Question 43

Q: If patient wants to get pregnant and she’s on mycophenolate mofetil and Sirolimus?

Answer 43

Needs to be stopped 6 months pre pregnancy

And switched to other immunosuppressive that are safer in pregnancy .

Question 44

The following summarizes the criteria for renal transplant recipients contemplating pregnancy (ensure good outcome of pregnancy)

Answer 44

At least 6 months after transplantation
 Stable allograft function and creatinine < 1.4 mg/dL
 No recent episodes of acute rejection
 Blood pressure ≤ 140/90 mmHg
 No or minimal proteinuria ≤ 500 mg/24 hours
 Prednisone ≤ 15 mg/day
 Azathioprine ≤ 2 mg/kg/day
 Stopping mycophenolate mofetil and sirolimus 6 weeks prior to conception

Question 45

How to counsel pregnant with Effect of pregnancy on kidney disease

Answer 45

• When initial renal function is normal or near normal ( S cr < 1.5mg) , 0 – 10 % of women will have permanent decline in renal function.
• Women with mod renal insuffiency ( S cr 1.5 – 2.9mg) : Large no. will have irreversible decline in GFR.
• Women with severe renal failure ( S cr > 3.0 mg) : Frequently have amenorrhea & no conception.
(Junger P et al . Lancet 1995:346)
( Imbasciati, et al . AMJK 2007;49:753)

Question 46

acute kidney injury (AKI) definitions

Answer 46

Current definitions include a rise in a serum creatinine level of at least 0.3 mg/dL within 48 hours, or ≥50 percent increase from baseline within a week, or urine output reduced to <0.5 mL/kg per hour for >6 hours.