RENAL DISEASE IN PREGNANCY

BY DR F.G. MHLANGA

INTRODUCTION
We have two kidneys weighing about 400 g each. Filters about 160 L per day producing about 1.5 L urine per day Complex process of filtering and reabsorption of plasma:Na+, bicarbonate, glucose, and amino acids

INTRODUCTION

INTRODUCTION
Functional unit of the kidney

1 million nephrons per kidney (250,000).

Key elements Glomerulus Proximal tubule Loop of Henle Distal tubule Collecting ducts

INTRODUCTION

Two scenarios important Effect of renal disease on pregnancy

Effect of pregnancy on renal disease

REVIEW OF PHYSIOLOGIC CHANGES

Renal plasma flow 50~70% esp 1st two trimesters. Maximal end of 2nd T. GFR : BUN & creatinine decreased Altered tubular function with Glycosuria Altered osmostat: Thirst & Na Physiologic Na retention & oedema

RENAL ANATOMIC CHANGES

Size Of 1 to 1.5cm Dilatation of ureters & pelvis R > L

Progesterone effect Dextrorotation Dilated venous plexus

RENAL DISEASE IN PREG~ ASYMPTOMATIC BACTERIURIA

In 2 to 10% of pregnancies Ascending infection : related to sexual intercourse 75 to 90 % E coli 30 to 40% get pyelonephritis if not treated

ASYMPTOMATIC BACTERIURIA
100 000/ml in clean catch MSU Treatment ~antibiotics: sensitivities Repeat urinalysis after resolution 15% recurrent bacteriuria If persistent may need suppressive therapy

ACUTE CYSTITIS
1% of pregnancy Frequency: dysuria:haematuria: pain Urine mcs : causative organisms: wcc:rbc If sterile~ ? Chlamydia Non medical treatment Antibiotics

ACUTE PYELONEPHRITIS
2% of pregnant females Bacterial infection Ecoli Klebsiella Enterobacter Proteus

ACUTE PYELONEPHRITIS
P/C~ abrupt: fever : chills: pain :vomiting etc Bacteremia: hemolysis:sepsis: ARDS:death Admit: iv fluids & antibiotics Renal function tests USS~ to exclude hydronephrosis, congenital abnormalities & calculi

PREGNANCY & PRE~EXISTING RENAL DISEASE

Reflux Nephropathy Diabetic Nephropathy SLE ( lupus) nephritis Polycystic Kidney Disease Glomerulonephritis

PREEXISTING RENAL DISEASE

Aetiology seems not important in prognosis except with lupus nephritis Degree of renal dysfunction @ conception important So too is presence & extent of cormobities esp hypertension & proteinuria Renal fx preserved with mild insuffiency & deteriorates in moderate to severe

CLASSIFYING RENAL INSUFFICIENCY

Mild ~creatinine < 125 umol/L

Moderate~ 125 to250umol/L About 50% loss of kidney fx

Severe~> 250umol/L Shouldn't conceive

WHY DETERIORATION

Cause not clear Worsening hypertension UTIs in pregnancy Proteinuria which increases in pregnancy

REMEMBER LUPUS NEPHRITIS

Flare up risk of failure 50% pts experience flare up in preg: less common if remission > 6 months Fetal loss occurs in up to 50% of pts Presence of lupus anticoagulant & anticardiolipin antibodies increase the risk

RENAL INSUFFICIENCY ON PREGNANCY

Increased Miscarriage Preterm labour IUGR SBs Perinatal mortality esp BP / nephrotic range proteinuria Pre~eclampsia

MX INSUFFICIENCY IN PREG
Joint Obs & physician Clinic Preconception care & counselling BP Proteinuria~ dipstick : 24hr urine Screen for bacteriuria & treat aggressively Check for anaemia ~ role of erythropoietin

MX INSUFFICIENCY
Risk of preeclampsia~ ? Low dose aspirin especially if hypertensive Fetal monitoring for growth USS Doppler uterine & umbilical arteries

Role of Biopsy

ACUTE RENAL FAILURE

Rare in preg < 0.005% Pre~renal causes : hypovoluemia Haemorrhage Low cardiac output states Burns G.I or renal losses Sepsis

ACUTE RENAL FAILURE

Renal( intrinsic) Acute tubular necrosis(reversible) Follows ischaemia or nephrotoxics Cortical necrosis Similar to above in presentation Diff by arteriogram/ biopsy No specific treatment available Thrombotic microangiopathies

ACUTE RENAL FAILURE

Post~renal Obstruction Easy to treat Difficult to diagnose May need IVU / retrograde pyelogram

ACUTE RENAL FAILURE

Differentiate btn renal and pre~renal causes CVP & urinary catheter

DIALYSIS PATIENTS

Marked In fertility (only 1 %) ~ ? anovular cycles, ? anaemia Generally preg contraindicated while on dialysis Fetal outcome poor nd T spontaneous abortions 2 23~55% of preg get surviving infants Significant morbidities in surviving infants 85% of surviving infants premature 28% are SGA

DIALYSIS PATIENTS

Maternal complication BP worsens in >80% pregnant women Worsening anaemia & transfusion rq During hemodialysis Avoid hypotension Full heparinisation & risk of bleeding Length/ freq to get urea 17 ~20mmol

TRANSPLANT PATIENTS

Better outcomes c.f. dialysis Concern with prednisolone NN adrenal insufficiency Thymic hypoplasia Azathioprine X placenta with SGA & dose related myelosuppression Teratogenic in animals Cyclosporine SGA

MX TRANSPLANT PATIENTS
Multidisciplinary approach Pregnancy Review medications~ eg stop ACE inhibitors BP , Protein, FBC, U&Es etc