Embed Size (px)
Citation preview
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
