Renal Disorders

Question 1

A creatinine above __ places pt at risk for progressive renal deterioration

Answer 1

About 10% of women with a Cr >/= 1.4 mg/dL will have progressive renal deterioration.

Question 2

What Cr is considered a pregnancy contraindication?

Answer 2

> 2.3 mg/dL

Question 3

Preconception counseling for renal txplant pts

Answer 3

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.

Question 4

What therapy may reduce preeclampsia risk in women with mod-severe renal insufficiency?

Answer 4

Low dose aspirin

Question 5

Definition of nephrotic syndrome

Answer 5

> 3.5 grams proteinuria in nonpregnant adults

Question 6

Live birth rate in lupus nephritis

Answer 6

Pts do well when in remission for 6 months prior to conception, with live birth rate up to 95%

Question 7

Predictors of adverse outcomes in lupus pts

Answer 7

Low complement levels at conception

Risk of flare incr w/ >1 gram proteinuria or GFR < 60 mL/min

Question 8

Permanent decline in renal function

Answer 8

In pts with mod-severe insufficiency (Cr >1.4), deterioration seen in 43%, of which 10% do not improve postpartum.

Question 9

Cr < 1.4, rate of complications

Answer 9

PTB 20%
Preeclampsia 11%
HTN 25%
FGR 24%
Perinatal mortality 9%
Live birth > 90%
Decline in renal function 16%

Question 10

Cr 1.4 - 2.8, rate of complications

Answer 10

PTB 36-60%
Preeclampsia 42%
HTN 56%
FGR 31-37%
Perinatal mortality 7%
Live birth > 90%
Decline in renal function 50%

Question 11

Cr >2.8, rate of complications

Answer 11

PTB 73-86%
Preeclampsia 86%
HTN 56%
FGR 43-57%
Perinatal mortality 36%
Live birth N/A
Decline in renal function 40%

Question 12

Dialysis, rate of complications

Answer 12

PTB 48-84%
Preeclampsia 20%
HTN 100%
FGR 50-80%
Perinatal mortality 60%
Live birth 40-50%
Decline in renal function N/A
Polyhydramnios 40%

Question 13

Renal transplant, rate of complications

Answer 13

PTB 52-75%
Preeclampsia 23-37%
HTN 47-63%
FGR 20-66%
Perinatal mortality 7%
Live birth 74-80%
Decline in renal function 14%

Question 14

Who should be prescribed ASA?

Answer 14

Low dose aspirin in pregnancy can improve outcome in patient with mod-severe CRI or hx lupus nephritis to reduce preeclampsia and FGR

Question 15

Causes of nephrotic syndrome

Answer 15

MCC outside of pregnancy:
Focal glomerulosclerosis
Membranous nephropathy
Minimal change disease
In pregnancy:
Hydatidiform mole

Question 16

Management of pregnancy in dialysis pts

Answer 16

Counseling regarding complications
Discuss termination, with better outcome p txplant
HD 6-7x/wk (increase prepregnancy regimen by 50%)
Plasma urea, predialysis, of 30-50 mg/dL (5-9 mmol/L) is assoc with improved outcomes
Peritoneal dialysis not recommended, but if pt already established on PD, no need to change to HD
Low BUN (7-10 mg/dL) to avoid fetal osmotic diuresis
Avoid maternal HTN (keep BP 130-150/80-90)
Avoid excessive fluid shifts
Keep bicarb 22-26, Hgb 11-12, replace Ca, Phos
Maternal serum screening for aneuploidy is unreliable
Consider delivery at 34-36w

Question 17

Goal immunosuppressant therapy in txplant patients

Answer 17

Maintenance levels:
Pred < 15 mg/d
Azathioprine < 2mg/kg/d
Cyclosporine <5 mg/kg/d
Tacrolimus crosses placenta, but no assoc w/ anomalies

Question 18

Management of pregnancy in transplant pts

Answer 18

Initial labs - CMV< toxo, HSV IgG/IgM, LFTs
Early 1 hr gtt if on prednisone or tacrolimus
Monthly CBC, BUN, Cr, electrolytes, serum urate, 24 hr CrCl and protein, urine culture.
Immunosuppressant levels q trimester

Question 19

Pyelonephritis rate w/ untreated ASB

Answer 19

24-40%, compared to 3% if treated

Question 20

Drug Interactions with Cyclosporine

Answer 20

There are many - look up before prescribing.
A few common drugs:
Gentamicin
Vancomycin
Ranitidine
Bactrim
Fluconazole

Question 21

Classification of Renal Insufficiency (based on creatinine)

Answer 21

Serum creatinine in early pregnancy:
Preserved < 1.1 mg/dL
Mildly impaired renal fxn 1.1-1.3 mg/dL
Moderate RI 1.4-2.8 mg/dL
Severe RI >2.8 mg/dL

Question 22

Stages of Chronic Kidney Disease (based on GFR)

Answer 22

1 - Kidney damage w/ nl or incr GFR >/= 90
2 - Kidney damage w/ mildly decr GFR 60-89
3 - Mod decr GFR 30-59
4 - Severely decr GFR 15-29
5 - Kidney failure < 15 or dialysis

Question 23

Rate of allograft rejection in pregnant pts

Answer 23

6%

Question 24

How is creatinine clearance calculated?

Answer 24

(Urine creatinine x volume)/(serum creatinine x 1440 minutes)