Renal Tx

Question 1

Antenatal care (aka how does it differ from normal pregnancy)

Answer 1

• Multi-D: include Tx team
• Baseline FBE/UEC/LFT/uPCR
• LDA 6-36
• 2/52 rv:BP/urinalysis (pet)
• 4/52 MSU (bacteruria)
• 4/52 UEC (renal function)
• 4/52 biometry/growth (FGR)
• Trimesterly 24-hr uPCR
• early GTT (if on pred)
• Aim VD (less graft injury)

Question 2

Mx of renal failure

Scenario 1 - 23yo renal tx+T1DM, 29/40

Answer 2

DDx
- Infection
- Rejection
- Dehydration
- Obstruction
- Preeclampsia
- Drug toxicity

Hx
- ?graft pain/swelling
- fever/low UOP/dysuria…
- FM, APH…PET sx
- medication compliance

Exam
- vitals - exclude PET
- CTG+RTS

Ix
- Bloods (renal function)
- MCS (reversible cause)

Mx
- MDI - MFM/Obs Med/Renal/ICU/Neo
- Deliver or not
- +/- Steroid+MgSo4
- Transfer to appropriate facility for care

Question 3

Intrapartum care

Answer 3

• stress dose (if on pred)
• graft don’t obstruct labor or get injured during labour
• con led/tx team if cs
• abx for perineal trauma

Question 4

Postpartum care

Answer 4

• Neonatologist review
• Contraception
• VTE prophylaxis
• Breastfeeding compatible meds
  tacrolimus
  azathioprine
  prednisolone

Question 5

Pre-preg counselling

Answer 5

Suitability for pregnancy
- >=1 years post tx
- relatively normal renal function
- no proteinuria
- no rejection
- no or well controlled HTN
- multi-D rv - MFM/Obs Med/renal/transplant physician
- contraception before all above met

Risks of the pregnancy
maternal
- worse renal function (no long term impact if cr <150), graft reject (rare 2-5%, not higher than non-preg state),
- HTN (1/3), proteinuria, UTI/other infections (CMV reactivation), anemia

foetal
- PTB (1/2)
- IUGR (1/3)

Question 6

Pre-preg ax

Answer 6

Hx
- re: tx - ?reason/date/meds/results
- re: tx cx - ?rejection ?UTI ?HTN
- O&G Hx - menstrual (EDD), CST (immunosuppression-HPV), contraception (allow optimize pre-preg)
- Med/Surg/FHx/SHx (smoke, etoh)

Exam
- weight/height, vitals (BP/RR/Temp), FWT
- cardio-resp, thyroid, breast, abdo-pelvic

Ix
- serology - rubella, VZ…rx & immunisable
- baseline FBE/UEC/LFT/24hr uPCR
- urine MCS

Commence folate/preg vitamins
Switch/cease (acei, mycophen, statins)
Preferred anti-HTN - methyldopa