Renal Disorders Flashcards
Ref: Evidence Based MFM, Creasy & Resnik
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 conception
Risk 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/A Decline 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/A Polyhydramnios 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 glomerulosclerosis Membranous nephropathy Minimal change disease In pregnancy: Hydatidiform mole
Management of pregnancy in dialysis pts
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
Goal immunosuppressant therapy in txplant patients
Maintenance levels: Pred < 15 mg/d Azathioprine < 2mg/kg/d Cyclosporine <5 mg/kg/d Tacrolimus crosses placenta, but no assoc w/ anomalies
Management of pregnancy in transplant pts
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
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: Gentamicin Vancomycin Ranitidine Bactrim Fluconazole
Classification of Renal Insufficiency (based on creatinine)
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
Stages of Chronic Kidney Disease (based on GFR)
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
Rate of allograft rejection in pregnant pts
6%
How is creatinine clearance calculated?
(Urine creatinine x volume)/(serum creatinine x 1440 minutes)
