Renal Disease in Pregnancy Ppt Powerpoint Presentation slides Alex C. Vidaeff, MD, MPH Medical Slideshow pregnancy and heart diseases

Renal Disease in Pregnancy

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sana on Sep 09, 2009 Says :

Ernest KIOKO on Apr 25, 2009 Says :

This is an EXCELLENT presentation. Congratulations.

crist on Apr 24, 2009 Says :

Thanks vidaeff for sharing this Excellent presentation.

Denise on Feb 26, 2009 Says :

Great presentation. I am a maternal fetal medicine specialist with a special interest in nephrology and found your slides to be excellent.

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Notes

Show Notes

Slide 1 :

RENAL DISEASE IN PREGNANCY Alex C. Vidaeff, MD, MPH Associate Professor UT-Houston 0

Slide 2 :

Population studies Renal disease in reproductive age women – 0.1% Pre-diagnosed renal disease in pregnancy – 0.03% Decreased fertility Less willingness to procreate Undiagnosed renal disease at conception 0

Slide 3 :

Focus of presentation A basis for advice in pregnancy or preconception Practical issues of obstetrical management 0

Slide 4 :

Timeline Before 1980 – pessimism was prevalent 1980 - Katz et al. Kidney Int (clinico-pathologic study of 121 pregnancies from 3 centers with minimally affected kidneys) After 1980 – cautious optimism 0

Slide 5 :

Literature Arbitrary opinions Retrospective data No randomized or comparative studies Insufficient data on moderately to severe renal impairment 0

Slide 6 :

Physiologic changes in pregnancy RPF 80% in 2nd trim 55% in 3rd trim Less in mild nephropathy No in severe impairment GFR 25% at 3-4 w 45% at 12 w Creatinine clearance - 50% (1st trim) Serum creatinine 0

Slide 7 :

Mean serum creatinine > 0.9 (or BUN > 14 mg/dL) is abnormal in pregnancy 0

Slide 8 :

Creatinine clearance Repeat testing before making decisions 0

Slide 9 :

Proteinuria Other causes proteinuria : - ambulatory - functional (exercise, cold, heat) - orthostatic (5%) 0

Slide 10 :

Determinants of maternal/fetal outcome Degree of renal function impairment - Mild (creatinine < 1.4) Moderate (1.4 to 2.4 – 2.8) Severe (> 2.4 – 2.8) ESRD (>6.0) > 2.0 – 23% ESRD within 6 months of delivery > 2.6 - 45% ESRD within a few years > 3.0 - rare conceptions, no live births recorded (Jungers. Clin Nephrol 1997) 0

Slide 11 :

Determinants of maternal/fetal outcome HTN Risk of preeclampsia increases from 50% to about 80% HTN at conception increases rate of fetal loss X 10 Diastolic > 100 at intake – no term deliveries (Misra. J Women’s Health 2003) PROTEINURIA 0

Slide 12 :

Slide 13 :

Dialysis indications Uremia BUN > 80 – increased risk IUFD Initiation dialysis at creatinine 4.0 – 4.5 – higher birthweight Volume overload Hyperkalemia Metabolic acidosis (pH<7.2) 0

Slide 14 :

Potentially nephrotoxic drugs Diuretics (salt retaining nephropathy may benefit) Beta-mimetics (may precipitate hypo-K in salt loosing renal nephropathy) Indocid (may precipitate hyper-K) MgSO4 (target level 5 mg/dL) Nifedipine is preferred for tocolysis 0

Slide 15 :

Chronic renal failure Q 2 w visits until 32 weeks Antepartum testing at 32 w (28 w if severe renal failure, diabetic nephropathy, or HTN) Delivery at 38 w Avoid prolonged inductions 0

Slide 16 :

Dialysis in pregnancy 1971 – first successful pregnancy with HD (Confortini. Proc Eur Dial Transplant Assoc 1971) 1988 – 90 successful pregnancies worldwide (25 on PD)(Chan. Int J Artif Organs 1998) 0

Slide 17 :

Dialysis in pregnancy 1st trim loss 30% 2nd trim loss 15% Live birth 52% Infant survival 37% Prematurity 85% Bagon. Am J Kidney Dis 1998 0

Slide 18 :

Dialysis in pregnancy Factors influencing fetal outcomes: Dialysis < 6 y Still producing urine > 50 mL/d Balance between efficacy (predialysis creatinine 4.5) and agressivity (risk of hypovolemia, hypotension, fetal hypoxia) 0

Slide 19 :

Dialysis in pregnancy Slow rate (4h), limited volume ultrafiltrate (<400 ml) sessions Increased frequency sessions (6/w) Less hydramnios Longer gestation Less IUGR Improved maternal nutrition Hypercalcemia Alkalosis 0

Slide 20 :

Dialysis in pregnancy Technical points: Left decubitus BP q 15 min EFM before, half-way, and after Contractions are frequently seen Fetal tachycardia indicates excessive fluid removal hCG and unconjugated estriol are increased (AFP unchanged) 0

Slide 21 :

Dialysis in pregnancy Technical points: Delivery at 34-36 w (with FLM) or at 37 w Resume dialysis 24 h after delivery Neonatal risks: volume depletion and electrolyte abn. tetany (if mother hypercalcemic) 0

Slide 22 :

Peritoneal dialysis Advantages: Less hypotension Less preeclampsia Higher birthweight Disadvantages: More PTD Risk peritonitis Abdominal fullness, nausea, anorexia, protein loss in dialysate Labial edema 0

Slide 23 :

PD vs HD Do not change modality in pregnancy Use standard criteria for start during pregnancy 0

Slide 24 :

Renal transplant 1963 – 1st successful pregnancy (Murray. NEJM 1963) 2000 – 7000 cases worldwide (Alston. Obstet Gynecol Surv 2001) 0

Slide 25 :

Renal transplant – fetal outcomes 1st trim loss - 15% Therapeutic ab - 30% Live birth beyond 1st trim – 95% Neonatal death – 3.5% IUGR – 40% Prematurity – 45-60%

Slide 26 :

Renal transplant – maternal complications (70%) Irreversible glomerular damage – 15% Allograft loss – 10% Worsening HTN – 33% Preeclampsia – 38% UTI – 40% Other infections (pneumocystis, toxoplasma, CMV, HSV, candida)

Slide 27 :

Factors influencing outcomes Time since transplant (>2y) Living donor BP controlled with only 1 agent Low dose immunosuppression Creatinine clearance > 70 Creatinine < 1.4 Proteinuria < 1g No pelvicaliceal distension

Slide 28 :

Renal transplant - recommendations Monthly urine culture Minimize urethral catheterizations Treat asymptomatic bacteriuria for 2 w and follow with suppression Prophylactic abx for delivery or surgery Baseline serology for hep B, CMV, toxo, HSV, and recheck in each trim.

Slide 29 :

Immunosuppression Do not change regimen in pregnancy Prednisone + azathioprine – 39% low-birth weight Prednisone + azathioprine + cyclosporine – 64% low-birth weight

Slide 30 :

Prednisone PTD < 7.5 mg/d – best outcome > 15 mg/d – risk neonatal adrenal suppression > 20 mg/d – risk infectious complications

Slide 31 :

Azathioprine (Imuran) Inhibitor purine metabolism Crosses placenta, but fetal liver lacks inosinate pyrophosphorylase to convert it to 6-mercaptopurine (active form) Skeletal and CNS anomalies in animals Damage germ cells and infertility in offspring after 6-mercaptopurine exposure in mice

Slide 32 :

Azathioprine (Imuran)(human data) Case reports: Thymic atrophy Marrow suppression Reduced IgG Neonatal infections Chromosome breaks Registry data - No significant problems if maternal WBC > 7.5K Best outcomes with < 2 mg/Kg/d Risk maternal liver toxicity at higher doses

Slide 33 :

Cyclosporine (Sandimmune) Calcineurin antagonist Crosses placenta No teratogenicity Autoantibodies in mouse offspring Abnormal T-cell maturation in human offspring Theoretical risk malignancy in mother and offspring

Slide 34 :

Cyclosporine (Sandimmune) Best outcomes - < 4 mg/Kg/d Risk maternal and fetal nephrotoxicity at higher doses Hypertension (67%) Diabetes (6%) Risk maternal liver toxicity, HUS, hyperuricemia, convulsions, tremor

Slide 35 :

Tacrolimus (Prograf) Calcineurin inhibitor Hypertension (27%) Diabetes (27%) Risk neonatal cardiomyopathy, renal toxicity, hyperkalemia

Slide 36 :

Immunosuppressants to be avoided Cyclophosphamide MTX Chlorambucil Leflunomide Mycophenolate mofetyl Rapamycin (Sirolimus) Monoclonal and polyclonal antibodies - cross the placenta - limited but reassuring short-term follow-up data on OKT3 (Muromonab) (Hou. Am J Kidney Dis 1999)

Slide 37 :

Breastfeeding Immunosuppressive conc. in milk similar to maternal blood (Newborn is exposed to higher conc. than fetus; but absorption is very low and blood concentrations of cyclosporine are undetectable. Thiru. BMJ 1997) Tacrolimus conc. in milk very low (Compatible with breastfeeding? Gardiner. OG 2006) Chronic low-dose exposure long-term consequences (nephrotoxicity, diabetes, lymphoma) are unknown Breastfeeding c-ind in immunosuppressed patients

Slide 38 :

Other pediatric issues Most children develop without behavioral problems and most parents adjust well (Korsch. Pediatrics 1980) Impressive catch-up growth in low-birthweight children (Willis. J Paediatr Child Health 2000) 16% need for educational support after cyclosporine in utero exposure (175 children in British National Register. 1999)

Slide 39 :

CMV Primary infection is common first 6 months after transplant Congenital infection is also possible through reactivation in immunosuppressed women Ganciclovir is c-ind in pregnancy (teratogenic in animals) One successful pregnancy after kidney transplant 1w after conception and exposure to ganciclovir and antithymocyte globulin (Miller. Transplantation 1995)

Slide 40 :

Allograft rejections during pregnancy (11%) Signs: Decline function Oliguria Renal enlargement, tenderness fever Diff Dx: Preeclampsia Infection Postrenal obstruction Bx. may be necessary

Slide 41 :

Recommendations Monthly renal U/S Technetium renal scan q trim. No live vaccines Vaginal delivery OK unless combined pancreas-kidney transplant.

Slide 42 :

Chronic renal anemia 100% incidence in ESRD ( erythropoietin, RBC’s survival) Erythropoietin requirements increase by 50% in pregnancy Target : Hgb > 8g/dL (Hct > 25%) with transfusions or EPO

Slide 43 :

EPO 27 cases reported (Kashiwagi. Arch Gynecol Obstet 2002) Does not cross placenta, no teratogenicity Rare side-effects (hyperkalemia, hyperphosphatemia, conjunctivitis, flu-like symptoms, seizures, HTN) Effective (Hgb > 10) in 2 w Do not exceed Hct 30%

Slide 44 :

EPO Support with 200 mg iron iv weekly Iron sucrose (Venofer) is safer than iron dextran or iron gluconate Follow reticulocytes, transferrin, ferritin, folate level Avoid excessive iron. It is disproportionately transferred to the fetus (risk of fetal iron toxicity)

Slide 45 :

Renal biopsy? Murakani.OG 2000 86 women with severe HTN and proteinuria in pregnancy 22% had renal disease on bx. in postpartum (63% IgA nephropathy) Baseline evaluation in pregnancy? Retrospective dx. at 6 months postpartum

Slide 46 :

Renal biopsy? More likely to present the signs < 30w Hx. of infection or renal toxic exposure (NSAID) Red cell casts in urine sediment “Rapidly deteriorating renal function or symptomatic nephrotic syndrome < 32 w in a patient with no hx. Indicates renal bx. In pregnancy.” (Lindheimer. J Reprod Med 1975) After 32 w, better deliver

Slide 47 :

Renal biopsy. Complications Gross hematuria Perirenal hematoma Severe flank pain Good BP control and no coagulopathy are prerequisites (or do it transjugular) < 29 w, rate of complications (5%) is the same as in non-pregnant women (Packham. Br J Ob Gyn 1987)

Slide 48 :

Diabetic nephropathy Most common chronic renal disorder in pregnancy Present in only 5-10% of pregnant women with DM (usually type 1) 10 y after delivery, 1/3 will have developed ESRD or died Renal disease progression in pregnancy – 32% (45% if creatinine > 1.4) Pregnancy c-ind if creatinine > 1.7 and HTN

Slide 49 :

Diabetic nephropathy - outcomes HTN > 60% Preeclampsia 41% PTD 30% IUGR 16% IUFD 5% Bacteriuria Worsening proteinuria 58%

Slide 50 :

Diabetic nephropathy - proteinuria There is no linear correlation with pregnancy outcome or kidney function progression - Better outcomes if <1g/d and CC>90 - Worse outcomes if >3g/d and serum creatinine > 1.5 before 20 w

Slide 51 :

Diabetic nephropathy - recommendations Replace ACE inhibitors with diltiazem (180 mg/d) (Khandelwal. J Matern Fetal Neonatal Med 2002) Target diastolic 90 No Glyburide (in renal failure half-life is 14 h; from 4h) For nephrotic syndrome with excessive edema : bedrest in lat decubitus, low-sodium diet, diuretics with caution Deliver at 32-36 w (pending on impairment renal function, preeclampsia development)

Slide 52 :

Lupus nephritis SLE doesn’t modify fertility 50% nephritis in SLE Outcome prognosticators: - degree renal failure - antiphospholipid antibodies - HTN - proteinuria Best outcomes if remission >1y before pregnancy

Slide 53 :

Antiphospholipid antibodies Increased production in pregnancy due to cytokine upregulation Hemolysis and myocardial conduction abnormalities in neonate No antibodies – 13% adverse fetal outcome Antibodies present – 76% adverse fetal outcome (including IUFD through placental thrombosis) (Moroni. Am J Kidney Dis 2002) RX: low-dose aspirin + heparin

Slide 54 :

Lupus nephritis – fetal loss (16-42%) HTN increases risk x 6 Proteinuria > 500 mg increases risk x 13.3 Risk increases if >20 mg/d prednisone needed If onset of nephrotic syndr. HTN, renal failure in pregnancy – loss 50% (termination justified)

Slide 55 :

Lupus nephritis – other outcomes PTD 13-53% IUGR 10-30% Preeclampsia 15% Renal function deterioration 33% Mesangial or membranous type 5% Diffuse proliferative type 50% (risk of PP anuria, sepsis, death; give steroids for 2-3 months)

Slide 56 :

Lupus flare vs preeclampsia Hypocomplementemia (including CH50) Increase in baseline anti-DNA antibodies

Slide 57 :

Primary glomerulonephritis Fetal loss 21% PTD 19% Worsening HTN 10-20% New onset HTN 20% Worse outcomes if nephrotic syndrome, HTN, renal function impairment are present in 1st trim

Slide 58 :

Primary glomerulonephritis types

Slide 59 :

Primary glomerulonephritis – Rx. Corticosteroids Cyclophosphamide – teratogenic in 1st trim Chlorambucil – c-ind in pregnancy

Slide 60 :

Reflux nephropathy Associated with HTN Risk UTI, pyelonephritis (highest risk – 18-57% - after childhood ureteric reimplantation) Risk renal function deterioration Fetal loss 12% IUGR, PTD, preeclampsia

Slide 61 :

Reflux nephropathy – outcome modifiers HTN increases risks (if uncontrolled, fetal loss x 5) Renal failure increases risks: - IUFD 37% - PTD 20% - irreversible kidney damage 20% When creatinine > 2.5 and CC < 30 – minimal chance of good outcome

Slide 62 :

Reflux nephropathy - recommendations Monitor for bacteriuria (if persistent, rotate 3 abx on a monthly basis) Monitor serum creatinine (deterioration may require temporary drainage) Serial kidney U/S or in case of flank pain, new HTN, decreased urine output Monitor proteinuria (increase indicates preeclampsia)

Slide :

	alex.c.vidaeff@uth.tmc.edu 9 Months ago. Category: Obstetrics and Gynecology

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General considerations regarding pregnancy adaptation in women with chronic renal disease, followed more General considerations regarding pregnancy adaptation in women with chronic renal disease, followed by discussion of specific preexistant renal conditions encountered in pregnancy. Practical aspects pertinent to dialysis and renal transplant in association to pregnancy are also addressed.- Slides less

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