Effect of pregnancy on the kidney

1
Effect of pregnancy on the kidney

• Increased plasma volume
• Increased intravascular volume
• Increased GFR
• Increased intraglomerular pressure
• Hyponatremia is frequently seen
• Hypokalemia can be seen

2
Pregnancy and renal disease

• Hormonal changes contribute to these changes
• Pregnant ladies gain 12 to 16 kilograms of
  weight mostly fluids
• Serum creatinine and BUN decreases in pregnancy
• Normal serum creatinine can be a sign of a
  significant renal disease
• Pregnancy affect renal disease and renal disease
  affect the outcome of pregnancy

3
Pregnancy and renal disease

• Pregnancy is associated in a decline in renal
  function in 1 -- 10 of cases when GFR is mildly
  reduced at the beginning of pregnancy Cr less
  than 1.5 mg/dl
• The rise in Cr is seen at the third trimester
• Transient decline in renal function may be seen

4
Moderate renal impairment

• Women with moderate renal insufficiency ( Cr
  between 1.5 and 2.9 mg/dl )
• In these patients there is a decline of Cr in the
  first trimester but rise above base line level
  as the pregnancy progress

5
3rd trimester
First trimester
76 women with pregnancy and moderate renal
impairment
Jones etal New Eng J 1996 335 226
6

• Some patients may have permanent decline in
  renal function
• In the previous study 10 of the women
  progressed to end stage renal disease
• The risk was highest in patients with a serum Cr
  above 2 mg/dl
• The risk of permanent decline in renal function
  is highest in the presence of uncontrolled
  hypertension

7

• Once serum creatinine exceed 3 mg /dl
  most women have amenorrhea or anovulatory cycles
  making the likelihood of pregnancy very small
• Some studies showed some link between the type of
  renal disease and outcome being worse in MPGN and
  reflux nephropathy

8
Effect of kidney disease on pregnancy

• Fetal survival is lowest with uncontrolled
  hypertension
• The relative risk of fetal death tenfold higher
  in women with a mean blood pressure greater than
  105 mmHg
• The risk of prematurity is increased when serum
  creatinine exceed 1.4 mg/dl
• Preterm delivery is not uncommon

9

• There is an increased risk of pre-eclampsia with
  increased fetal and maternal morbidity
• Pre-eclampsia might be more difficult to
  diagnose in the presence of baseline proteinuria
  and hypertension
• In this situation worsening of proteinuria and
  hypertension might be a clue to the diagnosis

10
Pregnancy in the dialysis patient

• The frequency of conception in this group is .3
  to 1.5 per year
• There is increase fetal wastage in this group
• Blood pressure and anemia may become more
  difficult to control in this group

11

• Hou an his group surveyed 1281 women of
  childbearing age on dialysis
• 1.5 became pregnant over tow years time
• 52 had surviving infants

Total no
Survivng infants
Hou,SH pregnancy in women on dialysis AM J Kid
Dis 1994 23 60
12
Pregnancy and dialysis

• Bogan in Belgium surveyed 1472 women of child
  bearing age on dialysis
• 1.5 became pregnant over tow years time
• 50 had successful out come of pregnancy

Bagon etal pregnancy and dialysis Am J of Kid
disease 1998 , 31 766
13
Dialysis and pregnancy

• There is improvement in the survival compared to
  old reports because of
• More intense dialysis with BUN below 17 mmol/l
  50 mg/dl ( almost daily dialysis )
• Higher dose of EPO is required to provide
  adequate red cell mass
• Metabolic acidosis and hypocalcaemia should be
  corrected

14
Pregnancy and dialysis

• Careful uterine and fetal monitoring during
  dialysis and through out the whole pregnancy
• Avoid hypotension during dialysis since this may
  provoke uterine contraction and fetal loss
• Nutritional status and dry weight should be
  assessed on frequent bases since intradialytic
  weight gain can be confused with the usual weight
  gain in pregnancy

15
Dialysis and fetal size

• In spite of optimal therapy mothers are at
  increased risk of sever hypertension and
  premature delivery with a mean gestational age
  of 30 weeks
• If the patient is a good potential candidate for
  transplant it is better to delay pregnancy tell
  she is transplanted

16
Case presentation

• A 24 year old saudi lady found to have raised
  creatinine when she was evaluated for primary
  infertility and a diagnosis of ESRD was made
• Her renal function continued to deteriorate and
  she was put on regular hemodialysis
• A cadaver transplant was done

17
Case presentation

• The transplant was successful and her serum Cr
  was around 1.2 mg/dl
• She was maintained on azathioprine steroids and
  cyclosporine
• She became pregnant 18 months post transplant
  with a full term twins
• Serum Cr post delivery was 1.3 mg
• One year later her serum Cr was 1.4
• She became pregnant

18
Case presentation

• Hb before gestation was 9.4 gm
• Hb decreased to 7.8 gm with more symptoms
• EPO was added and her anemia improved with Hb of
  11 at the time of delivery
• The outcome of the pregnancy was successful

19

• Erythropoietin Therapy in a Pregnant Post-Renal
  Transplant PatientSaad Al ShohaibDepartment of
  Medicine, King Khalid National Guard Hospital,
  Jeddah, Kingdom of Saudi Arabia
• Address of Corresponding Author
• Nephron 19998181-83 (DOI 10.1159/000045251)

20
Renal transplant

• Fertility return after transplant with a
  pregnancy success rate of more than 90 after the
  first trimester
• There is slight increase in spontaneous abortion
  and intrauterine growth retardation
• Pregnancy has no important early effect on renal
  function and affected by the same factors in
  pregnancy in patients with renal impairment

21
Renal transplant

• Women are advised to wait one year after living
  related transplant and tow years post cadaver
  transplant to avoid complications arising from
  rejection
• Neither low dose prednisolone or azathioprine
  appear to have adverse effect on the fetus
• The obstetrician should review the operative
  notes to confirm the location of the graft

22
cyclosporine

• Cyclosporine may aggravate or induce hypertension
  during pregnancy
• Cyclosporine does not appear to be a major
  teratogen
• Cyclosporine metabolism is increased during
  pregnancy and higher doses may be required to
  achieve adequate levels however there is
  controversy regarding adjusting the dose

23
Mycophenolate mofetil

• MMF should not be used in pregnancy as animal
  studies showed adverse effect on the fetus
• Patient that are welling to get pregnant should
  be converted to azathioprine

24
Sirolimus (Rapamycin )

• Sirolimus is contraindicated in pregnancy and
  should discontinued at least 12 weeks prior to
  pregnancy
• Cyclosporine should be used during gestation but
  once delivered sirolimus can be restarted

25
Tacrolimus (prograf )

• Kains reviewed 100 pregnancies in 84 women
  treated on prograf
• 27 were renal transplant recipients
• 68 progressed to alive birth
• Four babies had malformations

26
Obstetrical mangement

• Increase frequency of prenatal visit
• Early treatment of a symptomatic bacteriuria
• Monthly renal function
• Close monitoring for the development of pre
  eclampsia

27
SLE

• SLE occur frequently in women in child bearing
  age
• SLE patients are usually as fertile as other
  patients but their pregnancy is associated with
  more complication
• The prognosis is best for both the mother and
  fetus if SLE is quiescent for at least 6 months
  

28
SLE

• Exacerbation of the disease
• Fetal loss
• Neonatal lupus
• Breast feeding

29
Exacerbation of the disease

• 50 of patients will exacerbate their disease
  during pregnancy
• Flares occur in all three trimester and in the
  immediate postpartum period

30

• Ruiz prospectively evaluated 40 pregnancies in 37
  patients with SLE
• Flare up occurred in 24 cases 60
• Compared to the rates of flare up post delivery
  the rate is higher
• Flare up mainly as nephritis and arthritis

Ruiz etal increased rate of lupus flare up during
pregnancy Br J Rheum 1996 35133
31
Lupus nephritis

• There is increased risk of fetal loss
• Increased risk of worsening renal function as
  well as other manifestations of the disease
• Sever renal impairment requiring dialysis may
  occur
• Pre existing hypertension and azotemia are
  associated with worse prognosis

32
SLE following transplant

• The outcome is similar to other transplant
  patients

33
Comparison between SLE and Non SLE post renal
transplant pregnancy outcome
Live birth
abortion
Therapeutic termination
Mccy Groy etal pregnancy outcome Am J Transp
2003 335
34
pre eclampsia and SLE
P

• Preeclampsia is a frequent complication of SLE
  13
• It might be difficult to distinguish between
  preeclamsia and lupus nephritis
• Active urinary sediment is suggestive of lupus
  nephritis

35
Pre eclampsia and SLE

• Complement C3 C4 are low in lupus nephritis but
  normal in preeclamsia
• Anti DNA titer is increased in lupus nephritis
• Thrombocytopenia and raised liver enzymes are
  suggestive of preecalmpsia

36
Fetal loss and SLE risk factors

• Hypertension
• Lupus nephritis
• Low C3 high DNA
• Antiphospholipid antibody

37
Fetal loss and SLE
Petri etal fetal outcome of lupus pregnancy J
Rheum 1993 20 650
38
Hypertension and pregnancy

• Preeclamsia eclampsia
• Chronic hypertension (present before 20 weeks of
  pregnancy
• Preeclampsia superimposed on underlying
  hypertension
• Gestational hypertension (hypertension in after
  20 weeks without prteinuria

39
Hypertension preeclampsia

• Labetalol is the is the preferred therapy for
  sever hypertension
• Hydralazine is an acceptable alternative
• Methyldopa and labetalol the first line oral
  therapy
• Atenolol should be avoided in early pregnancy

40
Hypertension and pregnancy

• ACE inhibitors and ARBs are contraindicated
  during pregnancy since uterine and placental
  ischemia may occur
• Nitroprusside should be avoided (fetal cyanide
  poisinig)

41
Breast feeding

• Beta blockers and calcium channel blockers enter
  breast milk but are safe during lactation
• ACE inhibitors and ARBs should be avoided
• Diuretics reduce milk volume and should be avoided

42
Preexisting hypertension

• Has a strong on fetal and maternal outcome
• Preeclampsia 10 20
• Preterm birth 1234
• Growth retardation 816
• The higher the blood pressure the worse the
  outcome

43
ARF in pregnancy

• HUS TTP
• HELLP syndrome
• Renal cortical necrosis
• Acute pyelonephritis
• Acute fatty liver of pregnancy

44
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