Renal disease in pregnancyRenal disease in pregnancy

Dr. Ahmad S. AlkatheriDr. Ahmad S. Alkatheri

MDMD

Important points:Important points:

UTI → maternal morbidity + perinatal UTI → maternal morbidity + perinatal morbidity via Prematurity.morbidity via Prematurity.

Renal disease → Renal disease → PET + IUGR.PET + IUGR. Hypertension + proteinuria in first or early Hypertension + proteinuria in first or early

second trimester suggest pre-existing renal second trimester suggest pre-existing renal disease.disease.

Serum creatinine is mandatory to exclude pre-Serum creatinine is mandatory to exclude pre-existing renal disease.existing renal disease.

Physiological changes in pregnancyPhysiological changes in pregnancy

Ureters and renal calyces dilatation (remembered in Ureters and renal calyces dilatation (remembered in U/S).U/S).

↑ ↑ renal plasma flow + glomerular filtration → ↑ renal plasma flow + glomerular filtration → ↑ urinary protein excretion and ↑ creatinine clearance. urinary protein excretion and ↑ creatinine clearance. So:- So:-

The upper limit of serum creatinine clearance falls The upper limit of serum creatinine clearance falls 65 65 μμmol/L. mol/L.

The upper limit for proteinuria throughout pregnancy The upper limit for proteinuria throughout pregnancy is is 300mg/24 hours300mg/24 hours. .

Urinary tract infectionUrinary tract infection

Incidence:Incidence: It is more common in pregnancy due to It is more common in pregnancy due to

physiological dilatation of the upper renal physiological dilatation of the upper renal tract.tract.

Asymptomatic bacteriuria: 4-7%, 40% of Asymptomatic bacteriuria: 4-7%, 40% of them will develop symptomatic UTI.them will develop symptomatic UTI.

Cystitis: 1% of pregnancies.Cystitis: 1% of pregnancies. Pyelonephritis: 1 to 2% of pregnancies.Pyelonephritis: 1 to 2% of pregnancies.

Predisposing factorsPredisposing factors::

- previous history of UTI.- previous history of UTI.

- Diabetes millets, polycystic kidneys, urinary - Diabetes millets, polycystic kidneys, urinary tract calculi, renal tract abnormalities (duplex tract calculi, renal tract abnormalities (duplex kidney or ureter)kidney or ureter)

- Neuropathic bladder( spina bifida or multiple - Neuropathic bladder( spina bifida or multiple sclerosis). sclerosis).

- Drugs: steroids or immunosuppression. - Drugs: steroids or immunosuppression.

PresentationPresentation

AsymptomaticAsymptomatic: Asymptomatic bacteriuria + : Asymptomatic bacteriuria + patients with predisposing factors: midstream patients with predisposing factors: midstream urine specimens (antenatal screening).urine specimens (antenatal screening).

Clinical featuresClinical features include: include:

- - CystitisCystitis: urinary frequency, dysuria, : urinary frequency, dysuria, haematuria, protienuria and suprapubic pain.haematuria, protienuria and suprapubic pain.

- - PyelonephritisPyelonephritis: fever, loin pain and/or : fever, loin pain and/or abdominal pain, vomiting and rigors.abdominal pain, vomiting and rigors.

DiagnosisDiagnosis

Dipstick for proteinuria.Dipstick for proteinuria.

MSU for analysis. Bacteriuria: 100000 MSU for analysis. Bacteriuria: 100000 organisms/ml of urine or more organisms/ml of urine or more

MSU for culture and sensitivity. It should be MSU for culture and sensitivity. It should be repeated if it is non-significant or with mixed repeated if it is non-significant or with mixed growth.growth.

managementmanagement

Asymptomatic bacteriuriaAsymptomatic bacteriuria: a 3-day course of : a 3-day course of antibiotics (oral) to prevent pyelonephritis + antibiotics (oral) to prevent pyelonephritis + preterm labour.preterm labour.

Acute cystitisAcute cystitis: a 7-day course of antibiotics : a 7-day course of antibiotics (oral). (oral).

- Urine culture following treatment to ensure - Urine culture following treatment to ensure eradication of organisms. Recurrent bacteriuria eradication of organisms. Recurrent bacteriuria occurs in 15% of women in pregnancy and occurs in 15% of women in pregnancy and requires a second course of antibiotics.requires a second course of antibiotics.

- U/S: in patients with 2 or more UTIs (+ve - U/S: in patients with 2 or more UTIs (+ve culture).culture).

managementmanagement

Pyelonephritis:Pyelonephritis: - antibiotics for 10-14 days.- antibiotics for 10-14 days. - IV antibiotics for patients with - IV antibiotics for patients with vomiting or pyrexia.vomiting or pyrexia. - IV fluids may be required.- IV fluids may be required. - renal function should be checked.- renal function should be checked. - U/S to exclude hydronephrosis, renal calculi and - U/S to exclude hydronephrosis, renal calculi and

congenital abnormalities (congenital abnormalities (risk factorsrisk factors).).prophylactic antibioticsprophylactic antibiotics: two or more UTIs (positive : two or more UTIs (positive culture) i.e. recurrent UTI or one of the above risk culture) i.e. recurrent UTI or one of the above risk factors.factors.

Treatment regimens for UTI in pregnancyTreatment regimens for UTI in pregnancy

Oral antibioticsOral antibiotics:: - amoxicillin 500 mg tds.- amoxicillin 500 mg tds. - Cefadroxil 500mg bd. - Cefadroxil 500mg bd. - Cephalexin 250 mg tds.- Cephalexin 250 mg tds. - nitrofurantoin 100 mg - nitrofurantoin 100 mg

tds (not third trimester).tds (not third trimester). - trimethoprin 200 mg bd - trimethoprin 200 mg bd

(not first trimester).(not first trimester).

IV antibiotics for IV antibiotics for pyelonephritispyelonephritis::

- Cefuroxime 750mg tds- Cefuroxime 750mg tds - Augmentin 1gm tds - Augmentin 1gm tds - Gentamicin 2-5mg/kg - Gentamicin 2-5mg/kg

divided 8 hourly for divided 8 hourly for organism resistant to or organism resistant to or women allergic to women allergic to penicillin and penicillin and cephalosporincephalosporin

Prophylaxis of UTI: Prophylaxis of UTI:

- Cephalexin 250 mg od. - Cephalexin 250 mg od. - amoxicillin 250 mg od.- amoxicillin 250 mg od.

Renal impairmentRenal impairment

Aetiology:Aetiology:

1. reflux nephropathy 1. reflux nephropathy

2. diabetes2. diabetes

3. systemic lupus erythromatosus (SLE) 3. systemic lupus erythromatosus (SLE)

4.Glomerulonephritis.4.Glomerulonephritis.

5. polycystic kidney disease.5. polycystic kidney disease. ClassificationClassification: mild, moderate or severe depending on : mild, moderate or severe depending on

the serum creatinine.the serum creatinine.

creatinine depends on the muscle mass i.e. a figure creatinine depends on the muscle mass i.e. a figure representing moderate impairment in an 85-kg may representing moderate impairment in an 85-kg may represent severe impairment for a 50-kg woman.represent severe impairment for a 50-kg woman.

PresentationPresentation::

hypertension and protienuria ± haematuria in early hypertension and protienuria ± haematuria in early pregnancy. Blood tests for urea and creatinine must be pregnancy. Blood tests for urea and creatinine must be done.done.

Effect of pregnancy on renal Effect of pregnancy on renal impairment:impairment:

- mild impairment (creatinine < 125 - mild impairment (creatinine < 125 μμmol/l): tolerate mol/l): tolerate pregnancy well with no renal function deterioration.pregnancy well with no renal function deterioration.

- severe renal impairment (creatinine > 250 - severe renal impairment (creatinine > 250 μμmol/l): at mol/l): at increased risk of permanent loss of function during and increased risk of permanent loss of function during and after pregnancy and even end stage of renal failure.after pregnancy and even end stage of renal failure.

Effect of renal impairment on Effect of renal impairment on pregnancy :pregnancy :

1. PET, IUGR, spontaneous and iatrogenic premature delivery. 1. PET, IUGR, spontaneous and iatrogenic premature delivery.

- severe renal impairment + hypertension have < 50 % chance - severe renal impairment + hypertension have < 50 % chance of successful pregnancy because of severe, early-onset of PET of successful pregnancy because of severe, early-onset of PET with severe IUGR.with severe IUGR.

- premature delivery is justified in rapidly worsening renal - premature delivery is justified in rapidly worsening renal function to avoid dialysis even in the absence of PET.function to avoid dialysis even in the absence of PET.

2. severe renal impairment → polyhydramnios and risk of cord 2. severe renal impairment → polyhydramnios and risk of cord prolapse due to fetal polyuria in response to high osmotic load prolapse due to fetal polyuria in response to high osmotic load from increased maternal urea.from increased maternal urea.

3. nephrotic syndrome and heavy protienuria → severe 3. nephrotic syndrome and heavy protienuria → severe hypoalbuminria with associated risks of pulmonary oedema hypoalbuminria with associated risks of pulmonary oedema and thrombosis.and thrombosis.

management of renal impairmentmanagement of renal impairment • prepregnancy counseling and multidisciplinary care.prepregnancy counseling and multidisciplinary care.• Documenting baseline values (prepregnancy & early pregnancy) Documenting baseline values (prepregnancy & early pregnancy)

for creatinine, uric acid, albumin and protein.for creatinine, uric acid, albumin and protein.• Tight control of even mild hypertension with antihypertensive Tight control of even mild hypertension with antihypertensive

agents (the choice is no different in women with renal disease).agents (the choice is no different in women with renal disease).• discontinue angiotensin-converting enzyme (ACE) inhibitors discontinue angiotensin-converting enzyme (ACE) inhibitors

prior to pregnancy or once pregnancy is confirmed.prior to pregnancy or once pregnancy is confirmed.• Discontinue: diuretics unless there is severe hypoalbuminaemia Discontinue: diuretics unless there is severe hypoalbuminaemia

and insipient pulmonary oedema.and insipient pulmonary oedema.• Admission: in worsening hypertension, increasing creatinine, Admission: in worsening hypertension, increasing creatinine,

and large increase in proteinuria because of high risk of PET and large increase in proteinuria because of high risk of PET with difficult diagnosis in the present of ↑ BP + proteinuria.with difficult diagnosis in the present of ↑ BP + proteinuria.

management of renal impairmentmanagement of renal impairment

• Diagnosis of PET is supported by: IUGR, thrombocytopenia Diagnosis of PET is supported by: IUGR, thrombocytopenia and abnormal liver function.and abnormal liver function.

• Prophylactic low-dose(75 mg/day) aspirin to decrease the risk Prophylactic low-dose(75 mg/day) aspirin to decrease the risk of PET.of PET.

• Serial scans for fetal growth and liquor volume.Serial scans for fetal growth and liquor volume.• Serial haematology and biochemistry.Serial haematology and biochemistry.• If renal impairment discovered in pregnancy; not attribute it If renal impairment discovered in pregnancy; not attribute it

directly to PET but do: blood glucose (for diabetes), renal tract directly to PET but do: blood glucose (for diabetes), renal tract U/S (e.g. for polycystic or small kidney suggesting chronic U/S (e.g. for polycystic or small kidney suggesting chronic renal failure) and antinuclear antibodies (for SLE).renal failure) and antinuclear antibodies (for SLE).

• Post partum: continue close monitoring. ACE inhibitors are Post partum: continue close monitoring. ACE inhibitors are safely used in breastfeeding.safely used in breastfeeding.

Renal transplantsRenal transplants

Pregnancy outcome in well functioning renal transplants is Pregnancy outcome in well functioning renal transplants is similar to the general population.similar to the general population.

Pregnancy should be Pregnancy should be delayed for 1-2 yearsdelayed for 1-2 years to allow graft to allow graft function to stabilize and immunosuppression to reach function to stabilize and immunosuppression to reach maintenance levels.maintenance levels.

Risks in pregnancy: is related to pre-pregnancy renal function Risks in pregnancy: is related to pre-pregnancy renal function and to the presence of hypertension.and to the presence of hypertension.

Women are immunosuppressed and prone to infection.Women are immunosuppressed and prone to infection. Immunosuppressive drugs used in pregnancy: prednisolone, Immunosuppressive drugs used in pregnancy: prednisolone,

azathioprine, cyclosporine and tacrolimus.azathioprine, cyclosporine and tacrolimus. Women using cyclosporine and tacrolimus are advised not to Women using cyclosporine and tacrolimus are advised not to

breastfeed.breastfeed.

DialysisDialysis pregnancy on dialysis is unusual: end-stage renal pregnancy on dialysis is unusual: end-stage renal

failure reduces fertility.failure reduces fertility. Patients on dialysis should be advised not to get Patients on dialysis should be advised not to get

pregnant.pregnant. Common risks: Common risks: anaemia and haemorrhage.anaemia and haemorrhage. Increased risks of: Increased risks of: miscarriage, fetal death, pre-eclampsia, pre-term miscarriage, fetal death, pre-eclampsia, pre-term

labour, PROM, polyhydramnios and placental labour, PROM, polyhydramnios and placental abruption.abruption.

Pregnant women require increasing dialysis to Pregnant women require increasing dialysis to maintain the pre-dialysis urea < 15-20 mmol/l.maintain the pre-dialysis urea < 15-20 mmol/l.

Poor obstetric outcome is similar with both Poor obstetric outcome is similar with both haemodialysis and peritoneal dialysis. haemodialysis and peritoneal dialysis.

Acute renal failureAcute renal failure It is rare in pregnancy.It is rare in pregnancy. Commonest causes: pre-eclampsia, haemorrhage, infections, Commonest causes: pre-eclampsia, haemorrhage, infections,

drugs (NSAID) and obstruction due to ureteric damage or drugs (NSAID) and obstruction due to ureteric damage or stones.stones.

Most commonly complicates early post partum period.Most commonly complicates early post partum period. Characterized by: oliguria, a rising urea and creatinine, Characterized by: oliguria, a rising urea and creatinine,

metabolic acidosis and hyperkalaemia.metabolic acidosis and hyperkalaemia. In obstetrics there may be an associated coagulopathy.In obstetrics there may be an associated coagulopathy. A rise in urea (without concomitant rise in creatinine) is A rise in urea (without concomitant rise in creatinine) is

observed following antenatal corticosteroid administration.observed following antenatal corticosteroid administration. haemolytic uraemic syndrome: rare cause, occurs postpartum, haemolytic uraemic syndrome: rare cause, occurs postpartum,

associated with renal failure + thrombocytopenia. associated with renal failure + thrombocytopenia. characterized by microaniopathic haemolytic anaemia characterized by microaniopathic haemolytic anaemia (diagnosed on blood film). (diagnosed on blood film).