Renal disorders Flashcards
A creatinine above __ places pt at risk for progressive renal deterioration
About 10% of women with a Cr >/= 1.4 mg/dL will have progressive renal deterioration.
What Cr is considered a pregnancy contraindication?
> 2.3 mg/dL
Preconception counseling for renal txplant pts
Wait one to two yrs post txplant before attempting pregnancy, overall live birth rate of >90%. Nl BP (diastolic < 90) ideal, or controlled on just one agent.
What therapy may reduce preeclampsia risk in women with mod-severe renal insufficiency?
Low dose aspirin
Definition of nephrotic syndrome
> 3.5 grams proteinuria in nonpregnant adults
Live birth rate in lupus nephritis
Pts do well when in remission for 6 months prior to conception, with live birth rate up to 95%
Predictors of adverse outcomes in lupus pts
Low complement levels at conceptionRisk of flare incr w/ >1 gram proteinuria or GFR < 60 mL/min
Permanent decline in renal function
In pts with mod-severe insufficiency (Cr >1.4), deterioration seen in 43%, of which 10% do not improve postpartum.
Cr < 1.4, rate of complications
PTB 20%Preeclampsia 11%HTN 25%FGR 24%Perinatal mortality 9%Live birth > 90%Decline in renal function 16%
Cr 1.4 - 2.8, rate of complications
PTB 36-60%Preeclampsia 42%HTN 56%FGR 31-37%Perinatal mortality 7%Live birth > 90%Decline in renal function 50%
Cr >2.8, rate of complications
PTB 73-86%Preeclampsia 86%HTN 56%FGR 43-57%Perinatal mortality 36%Live birth N/ADecline in renal function 40%
Dialysis, rate of complications
PTB 48-84%Preeclampsia 20%HTN 100%FGR 50-80%Perinatal mortality 60%Live birth 40-50%Decline in renal function N/APolyhydramnios 40%
Renal transplant, rate of complications
PTB 52-75%Preeclampsia 23-37%HTN 47-63%FGR 20-66%Perinatal mortality 7%Live birth 74-80%Decline in renal function 14%
Who should be prescribed ASA?
Low dose aspirin in pregnancy can improve outcome in patient with mod-severe CRI or hx lupus nephritis to reduce preeclampsia and FGR
Causes of nephrotic syndrome
MCC outside of pregnancy:Focal glomerulosclerosisMembranous nephropathyMinimal change diseaseIn pregnancy:Hydatidiform mole
Management of pregnancy in dialysis pts
Counseling regarding complicationsDiscuss termination, with better outcome p txplantHD 6-7x/wk (increase prepregnancy regimen by 50%)Plasma urea, predialysis, of 30-50 mg/dL (5-9 mmol/L) is assoc with improved outcomesPeritoneal dialysis not recommended, but if pt already established on PD, no need to change to HDLow BUN (7-10 mg/dL) to avoid fetal osmotic diuresisAvoid maternal HTN (keep BP 130-150/80-90)Avoid excessive fluid shiftsKeep bicarb 22-26, Hgb 11-12, replace Ca, PhosMaternal serum screening for aneuploidy is unreliableConsider delivery at 34-36w
Goal immunosuppressant therapy in txplant patients
Maintenance levels:Pred < 15 mg/dAzathioprine < 2mg/kg/dCyclosporine <5 mg/kg/dTacrolimus crosses placenta, but no assoc w/ anomalies
Management of pregnancy in transplant pts
Initial labs - CMV< toxo, HSV IgG/IgM, LFTsEarly 1 hr gtt if on prednisone or tacrolimusMonthly CBC, BUN, Cr, electrolytes, serum urate, 24 hr CrCl and protein, urine culture. Immunosuppressant levels q trimester
Pyelonephritis rate w/ untreated ASB
24-40%, compared to 3% if treated
Drug Interactions with Cyclosporine
There are many - look up before prescribing.A few common drugs:GentamicinVancomycinRanitidineBactrimFluconazole
Classification of Renal Insufficiency (based on creatinine)
Serum creatinine in early pregnancy:Preserved < 1.1 mg/dLMildly impaired renal fxn 1.1-1.3 mg/dLModerate RI 1.4-2.8 mg/dLSevere RI >2.8 mg/dL
Stages of Chronic Kidney Disease (based on GFR)
1 - Kidney damage w/ nl or incr GFR >/= 902 - Kidney damage w/ mildly decr GFR 60-893 - Mod decr GFR 30-594 - Severely decr GFR 15-295 - Kidney failure < 15 or dialysis
Rate of allograft rejection in pregnant pts
6%
How is creatinine clearance calculated?
(Urine creatinine x volume)/(serum creatinine x 1440 minutes)
