Mamdouh Albaqumi, MD, FASN Nephrology Section Department of Medicine King Faisal Specialist Hospital...

Mamdouh Albaqumi, MD, FASNNephrology Section

Department of MedicineKing Faisal Specialist Hospital

Hypertension and CKD in the Pregnancy

How many pregnant patients with CKD did you treat?

More

than

4

2 to

4

1 to

2

None

0% 0%0%0%

1. More than 4

2. 2 to 4

3. 1 to 2

4. None

How many pregnant patients on Dialysis did you treat?

More

than

4

2 to

4

1 to

2

None

0% 0%0%0%

1. More than 4

2. 2 to 4

3. 1 to 2

4. None

Case Presentation

She was diagnosed with vesicouretheral reflux at age 8,

Renal function was normal.

UA: trace protein, 0 RBC

Renal US increased echogenicity.

Nuclear scan: 23% function of R kidney.

History:

Chief complain: Patient is 29 years old Female who presented to ER at 18 weeks gestation with uncontrolled hypertension and Cr 370 umol/L

Chief complain: Patient is 29 years old Female who presented to ER at 18 weeks gestation with uncontrolled hypertension and Cr 370 umol/L

Case Presentation

Lost follow up for years

Had 2 pregnancies, 2000, 2006 both resulted in still

birth in her second trimester

In 2006: Cr 151- 195 umol/L, UA : +1 Protein, 0 RBC

History:

Chief complain: Patient is 29 years old Female who presented to ER at 18 weeks gestation with uncontrolled hypertension and Cr 370 umol/L

Chief complain: Patient is 29 years old Female who presented to ER at 18 weeks gestation with uncontrolled hypertension and Cr 370 umol/L

Labs:

Liver function Test, LDH, Uric acid normal Platelets 370 Hgb 84 Lupus screen, Complements, Anti phospholipids: normal UA+1 protein, 0 RBC, 24 hour collection: 980mg protein/24h Uterine US: 19 weeks Fetus Renal US: bilateral echogenic kidneys

On admission: BP 180/110 No edema

Case Presentation

Urea Creat. K HCO3 GFR

30 mmol/L 370 umol/L 4.3 mmol/L 16 mmol/L 14 ml/min

With the current lab data, How would you treat the patient next?

Em

erge

nt C-S

ec...

Dia

lysi

s

Contro

l the

bl...

0% 0%0%

1. Emergent C-Section

2. Dialysis

3. Control the blood pressure, correct the anemia, and monitor closely.

What are the indication for initiating dialysis in moderate to severe CKD (other than uremia and metabolic abnormalities)?

0% 0%0%0%

1. Uncontrolled hypertension

2. Urea more than 30 umol/L

3. DNo maternal indication, but you must start dialysis to improve fetal outcome.

4. No strong evidence to start dialysis

Registry Of Pregnancy In Dialysis Patients

Therapeutic Abortion

Still Pregnant

Surviving Infants

Neonatal Deaths

Stillbirths

Spontaneous Abortion 1st Trimester

Spontaneous Abortion 2nd Trimester

Okundaye et al. AJKD, Vol 31, No 5 (May), 1998: pp 766-773

Registry Of Pregnancy In Dialysis Patients

Therapeutic Abortion

Still Pregnant

Surviving Infants

Neonatal Deaths

Stillbirths

Spontaneous Abortion

1st Trimester

Spontaneous Abortion 2nd Trimester

Okundaye et al. AJKD, Vol 31, No 5 (May), 1998: pp 766-773

Still Pregnant

Surviving Infants

Spontaneous Abortion 2nd Trimester

Spontaneous Abortion 1st Trimester

Stillbirths

Neonatal Deaths

Conceived after starting dialysisn=184

Conceived prior to dialysisn=57

Pregnancy in Moderate to Severe CKD

Jones et al. NEJM. 1996. July. 226-234

Surviving Infants

Neonatal Deaths& Stillbirths

>40 % preterm delivery, >10%fetal distress

CKD

Still Pregnant

Therapeutic Abortion

Surviving Infants

Neonatal Deaths

Stillbirths

Spontaneous Abortion

1st Trimester

Spontaneous Abortion 2nd Trimester

ESRD

Degree of renal failure Proposed Management

ESRD on dialysis Intensify treatment

GFR less than 10ml/min gets pregnant start dialysis

GFR 10- 30 ml/min ??????

What is the optimal blood pressure target in this patient?

Les

s th

an 1

40/..

.

Les

s th

an 1

20/..

.

MAP ta

rget

of .

..

No e

viden

ce to

...

0% 0%0%0%

1. Less than 140/90

2. Less than 120/80

3. MAP target of 70 to ensure placental perfusion

4. No evidence to support a target BP

The Control of Hypertension In Pregnancy Study CHIPS

Magee at al. BJOG. 2007 Jun;114(6):770

N =132 women Less tight BP control

DBP 100Tight BP control

DBP 85

serious maternal complications

3.1% 4.6%

preterm birth 36.4% 40.0%

birth weight 2675 +/- 858g 2501 +/- 855 g

neonatal intensive care unit (NICU) admission

22.7% 34.4%

serious perinatal complications

13.6% 21.5%

Can we start CAPD in this patient?

Yes

, PD c

an s

a...

PD c

an b

e in

it...

No, H

D is th

e ...

0% 0%0%

1. Yes, PD can safely be initiated

2. PD can be initiated only if HD is unsuccessful

3. No, HD is the only safe dialysis modality

Registry Of Pregnancy In Dialysis Patients

Therapeutic Abortion

Surviving Infants

Neonatal DeathsStillbirths

Spontaneous Abortion

1st Trimester

Spontaneous Abortion 2nd Trimester

Okundaye et al. AJKD, Vol 31, No 5 (May), 1998: pp 766-773

Still Pregnant

Surviving Infants

Spontaneous Abortion 1st Trimester

Stillbirths

Neonatal Deaths

Spontaneous Abortion

1st Trimester

Therapeutic Abortion

Peritoneal Dialysisn=35

Hemodialysisn=149

BP was controlled with methyldopa, labetolol, hydralazine

140-120/90-80

Urea: 30 to 21mmol/L within 1 week

Creatinine: 370 to 312 umol/L

At week 24: controlled BP, Urea 16mmol/L Cr 310umol/L

Follow UP

Thank You