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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Renal Disease and Pregnancy
Matt Hall
Nottingham Renal Unit
SpR Club Belfast
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Sex
Drugs
Rock and roll
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Sex
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
0
10
20
30
40
50
60
70
80
90
England andWales
CKD Transplant(Belfast)
Dialysis Dialysis inToronto
Conc
eptio
n ra
te (p
er 1
000
wom
en/y
ear)
?
National Statistics Online. Conception statistics 2008. http://www.statistics.gov.uk/downloads/theme_health/conceptions2008/conceptions08.pdfBrown JH, Maxwell AP, McGeown MG. Irish J Med. 2001
Barua M, Hladunewich M, Keunun J et al. Clin J Am Soc Nephrol. 2008;3:392/396
Pregnancy and CKD
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and CKD
Dialysis, 20
CKD 3-4, 240
CKD 1-2, 960
UK, 800000
Approximate number of pregnancies per year in UK
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Maternal and fetal risks
Maternal risks
Is pregnancy going to make my kidney disease worse?
Fetal risks
Will I take home a healthy baby?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Maternal and fetal risks
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Factors associated with adverse outcomes
Baseline renal function?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Baseline renal function?
0
10
20
30
40
50
60
70
80
90
100
IUGR Preterm delivery Pre-eclampsia Perinatal death
%
<125
125-180
>180
Dialysis
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Baseline renal function?
0
10
20
30
40
50
60
70
80
Loss of >25% renal functionduring pregnancy
Persistent loss of >25% renalfunction
ESRD after 1 year
%
<125
125-180
>180
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
0
20
40
60
80
100
120
140
Baseline serum creatinine
Base
line
seru
m cr
eatin
ine
(μm
ol/l
)
PALRF
No PALRFp=0.027
Baseline renal function?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Baseline renal function?
0
20
40
60
80
100
120
Caesarean Section Preterm delivery Small for gestational age Neonatal ICU admission
ControlCKD 1CKD 2CKD 3CKD 4-5
*
*
** **
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Factors associated with adverse outcomes
Baseline renal function - yes
Baseline blood pressure?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Blood pressure?
Neonatal death
0
5
10
15
20
25
<70 70-80 80-90 >90 or treated
Diastolic blood pressure in early pregnancy (mmHg)
Odd
s ra
tio
Neonatal death risk
Diastolic BP Absolute risk
<70 0.9%
70-80 3.2%
80-90 3.6%
>90 or treated 15.3%
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Blood pressure?
0
20
40
60
80
100
120
140
160
Systolic BP Diastolic BP
Mea
n bl
ood
pres
sure
(mm
Hg)
PALRFNo PALRF
p=0.08
p=0.009
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Blood pressure?
• 43 pregnancies in 30 women with CKD (serum creatinine 110 to 490 μmol/l)• Hypertension was present from conception in 26 (60%).• Logistic regression identified uncontrolled hypertension at conception as an independent risk factor for fetal death• RR fetal death with MAP> 105mmHg at conception = 10.5• Accelerated loss of maternal renal function in 7 patients, all of whom had hypertension
• 168 pregnancies in 118 women with IgA nephropathy.• Perinatal mortality 33% in women with BP>140/90 versus 1% with BP<140/90• (Hypertension not identified as a risk factor for progression of maternal disease.)
Jungers P et al. Pregnancy in women with impaired renal function. Clin Nephrol 1997;47(5):218-288Abe S. Pregnancy in IgA nephropathy. Kidney International 1991;40:1098-1102
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Factors associated with adverse outcomes
Baseline renal function - yes
Baseline blood pressure - yes
Proteinuria ?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Proteinuria
Women without CKD
Second trimester ACR>3mg/mmol
Second trimester ACR>20mg/mmol
OR 1.9 preterm delivery
OR 4.7 preterm deliveryXDiabetes and hypertension
Franceschini N et al. Maternal urine albumin excretion and pregnancy outcome. Am J Kindy Dis. 2005’45(6):1010-1018Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. New Engl J Med 1991;336(4):226-223
Hemmelder MH et al. Proteinuria: a risk factor for pregnancy-related renal function decline in primary glomerular disease? A,m J Kidney Dis 1995;2691):187-192
Women with CKDCreat > 124μmol /l
Proteinuria > 3g/d
Proteinuria < 3g/dNo impact on outcome
Women with CKD
Pregnancy (n=19)
No pregnancy (n=31)
Proteinuria andpregnancy assoc with
PALRF
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Proteinuria?
Imbasciati E et al. AJKD 2007;49:753
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Proteinuria?PALRF
Yes No p value
n 6 21
Maternal age (years) Mean (SD) 33.0 (3.7) 30.4 (3,3) 0.103
Gravidity Median (range) 3 (1-4) 3 (1-5) 0.057
Underlying glomerular disease n (%) 2 (33%) 13 (69%) 0.357
Baseline serum creatinine (μmol/l) Mean (SD) 111 (46) 81 (20) 0.027
Baseline eGFR (ml/min) Mean (SD) 63 (28) 79 (16) 0.077
Baseline protein:creatinine ratio
(mg/mmol creatinine)
Median (IQR) 29 (206) 46 (272) 0.345
Rate of decline in eGFR prior to conception (ml/min/year)
Median (IQR) 0.44 (4.15) -0.50 (3.52) 0.932
Baseline systolic BP (mmHg) Mean (SD) 143.1 (18.3)
136.6 (20.8)
0.08
Baseline diastolic BP (mmHg) Mean (SD) 81.0 (4.7) 71.6 (9.7) 0.009
Receiving antihypertensives n (%) 5 (83.3%) 7 (33.3%) 0.003
Table. Demographic and clinical parameters of study cohort
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Proteinuria
0
10
20
30
40
50
60
70
80
90
100
Fetal Survival Low birth weight Preterm delivery
%
Proteinuria<100mg/mmol creatinineProteinuria>100mg/mmol creatinine
p=0.60
p=0.86
p=0.03
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Factors associated with adverse outcomes
Baseline renal function - yes
Baseline blood pressure - yes
Proteinuriamaternal? no
fetal? yes
Aetiology of kidney disease?
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Aetiology of kidney disease?Perinatal
lossPretermdelivery
Renal function decline
Permanent blood pressure increase
FSGS (n=85) 23% 32% 13% 10%
Membranous GN (n=110) 4% 35% 3% 3%
IgA nephropathy (n=268) 15% 21% 12% 12%
MC GN (n=278) 12% 9% 2% 7%
Diabetic nephropathy (n=97) 6% 36% 32% 58%
Polycystic disease (n=464) 3% 10% 3% 14%
Reflux nephropathy (n=137) 7% 15% 0.7% 11%
Comparison of pregnancy outcomes by aetiology of CKD. FSGS, focal segmental glomerulosclerosis; GN, glomerulonephritis; MC, mesangiocapillary.No co
nvincin
g evidence
of effe
ct
of aetio
logy on outco
mes
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Aetiology of kidney disease?
SLE
Hypertension
Medication
Anti-Roantibodies
Antiphospholipidsyndrome
Renaldysfunction
All associated with adverseoutcomes
Not the “SLE” label itself
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Aetiology of kidney disease?
Reflux nephropathy
Increased riskof pyelonephritis
Maternalmortality
Pretermlabour
Neonatal morbidityand mortality
Increased riskof UTI
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Aetiology of kidney disease?
Diabetes
0
5
10
15
20
25
30
35
Unknown
Glomerulonephriti
s
Pyelonep
hritis
Diabetes
Renal va
scular
disease
Hypert
ension
Polycysti
c dise
ase Other
Perc
enta
ge o
f cas
es
End stage renal disease
CKD and pregnancy
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Aetiology of renal disease?
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Factors associated with adverse outcomes
Baseline renal function - yes
Baseline blood pressure - yes
Proteinuriamaternal? no
fetal? yes
Aetiology of kidney disease – not really
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Management of CKD and hypertension in pregnancy
Hawk-like observation Masterful inactivity
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Management of CKD in pregnancy
Limited interventions
Medicinesmanagement
Blood pressurecontrol
Pre-eclampsiaprophylaxis
Thrombo-prophylaxis
Urinary tract infectiontreatment
Timing of delivery
Preconceptioncounselling
Imm
unos
uppr
essa
nt
twea
kage
Dialysismanipulation
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Management of CKD and hypertension in pregnancyPre-eclampsia prophylaxis
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Aspirin 75mg odSystematic review
37560 women
All women
17% relativerisk reduction
High risk women
25% relativerisk reduction
NNT = 72 NNT = 19
Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst.Rev. 2007 Apr 18;(2)(2):CD004659.
Preterm delivery RRR 8%
Perinatal death RRR 14%
SGA RRR 10%
Management of CKD and hypertension in pregnancyPre-eclampsia prophylaxis
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• Not evidence based
• Different practices between (and within) centres.
Management of CKD and hypertension in pregnancyThrombo-prophylaxis
Nephrotic syndromeRR VTE = 1.7
PregnancyRR VTE = 4.3
?Heavy proteinuriaRR VTE = ?
PregnancyRR VTE = 4.3
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Management of CKD and hypertension in pregnancyThrombo-prophylaxis
Add-up risk factors
Prophylactic LMWH No treatment
Treat until 6 weekspostpartum
If renal impairment,monitor Factor Xa levels
Low threshold forinvestigating suspected VTE
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Management of CKD and hypertension in pregnancyUrinary tract infection
Asymptomatic bacteruria Pyelonephritis4x increased risk
in pregnancy
21% risk of progression if untreated
Treatment of asymptomatic bacteruria in pregnancy reduces the incidence of
pyelonephritis by 75%
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Management of CKD and hypertension in pregnancyUrinary tract infection
…Antibiotic treatment of asymptomatic bacteruria is indicated to reduce the risk of pyelonephritis in pregnancy…
Based on studies from 1960-1970s
…Antibiotic treatment of asymptomatic bacteruria was associated with a reduction in the incidence of low birth weight babies (RR 0.66 (0.49-0.89))…
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Management of CKD and hypertension in pregnancyUrinary tract infection
Asymptomatic bacteruria PyelonephritisNon-pyelonephriticUTI
Preterm birth7.2%
Preterm birth7.7%
Preterm birth8.3%
Small for gestational age16.1%
Small for gestational age16.5%
Small for gestational age18.9%
n=85,484
After adjusting for confounding covariates, no increased risk of preterm birth orsmall infant in women exposed to urinary tract infection.
Chen YK et al. Acto Obstet Gynecol Scand 2010;89(7):882-888
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Management of CKD and hypertension in pregnancyUrinary tract infection
Asymptomatic bacteruria
Pyelonephritis
Non-pyelonephriticUTI
In pregnancy
Treat
Asymptomatic bacteruria
Pyelonephritis
Non-pyelonephriticUTI
Treat
Second or more episode in pregnancy?
Prophylaxis
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Management of CKD and hypertension in pregnancyBlood pressure control
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Management of CKD and hypertension in pregnancyBlood pressure control
Chronic hypertension Target BP <150/100
Chronic hypertension+ CKD
Target BP <140/90
Do not treat to DBP<80mmHg
Chronic hypertension+ proteinuric CKD
Target BP ?and treat with what?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Chronic hypertension+ proteinuric CKD
Target BP <140/90
Management of CKD and hypertension in pregnancyBlood pressure control
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
0
10
20
30
40
50
60
70
80
90
England andWales
CKD Transplant(Belfast)
Dialysis Dialysis inToronto
Conc
eptio
n ra
te (p
er 1
000
wom
en/y
ear)
?
National Statistics Online. Conception statistics 2008. http://www.statistics.gov.uk/downloads/theme_health/conceptions2008/conceptions08.pdfBrown JH, Maxwell AP, McGeown MG. Irish J Med. 2001
Barua M, Hladunewich M, Keunun J et al. Clin J Am Soc Nephrol. 2008;3:392/396
Pregnancy and dialysis
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
An average sized renal unit in the UKwould expect to treat one pregnant patient
on dialysis every four years
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
How do you diagnosispregnancy in a woman on dialysis?
Amenorrhoea? Pregnancy test from Boots?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
How do you diagnosispregnancy in a woman on dialysis?
Intradialytic hypotension?
Serum βhCG Early ultrasound
Elevated Serum βhCG but no fetal heart beat?
Serial βhCG Repeat ultrasoundin 1-2 weeks
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
Target weight Increase by 1.5kg over first trimester
0.2-0.4 kg/week from week 15
Weekly clinical evaluation
Blood pressure Target blood pressure <140/90
Do not treat to DBP<80mmHg
Anaemia ESA requirement increases by 85% at 28 weeks
Target Hb 10-11g/dl
Nutrition Protein intake >1.8g/kg/day
Energy intake 30kcal/kg/day
Water soluble vitamin and folic acid supplementation
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
Befriend an obstetrician
• Fetal growth monitoring every 1 – 2 weeks• Liquor volume monitoring every 1 -2 weeks• CTG monitoring every dialysis session from 25 weeks
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
PD?
Yes!• Conception rates may be lower• Infection rates no higher• No contraindication to Caesarean
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
HD?
Yes!
How much?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
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30
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50
60
70
80
90
100
IUGR Preterm delivery Pre-eclampsia Perinatal death
%
<125
125-180
>180
Dialysis
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
0%
10%20%
30%
40%50%
60%
70%
80%90%
100%
<14 hours/week 15-19 hours/week >20 hours/week
Dialysis duration
Infa
nt s
urvi
val
Hou S. Hemodialysis International 2004;8:167-171
p<0.05
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
0%
10%20%
30%
40%50%
60%
70%
80%90%
100%
<14 hours/week 15-19 hours/week >20 hours/week
Dialysis duration
Pret
erm
del
iver
y
Hou S. Hemodialysis International 2004;8:167-171
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
0%10%20%30%40%50%60%70%80%90%
100%
<14hours/week
15-19hours/week
>20hours/week
48±5hours/week
Dialysis duration
Infa
nt s
urvi
val
Hou S. Hemodialysis International 2004;8:167-171Barua M et al. Clin J Am Soc Nephrol 2008;3:392-396
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
0%10%20%30%40%50%60%70%80%90%
100%
<14hours/week
15-19hours/week
>20hours/week
48±5hours/week
Dialysis duration
Pret
erm
del
iver
y
Hou S. Hemodialysis International 2004;8:167-171Barua M et al. Clin J Am Soc Nephrol 2008;3:392-396
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Pregnancy and dialysis
Historic observations Nocturnal HD
Preterm delivery 90% 50%
IUGR/SGA 90% 17%
Pre-eclampsia 75% 0%
Perinatal death 50% 17%
Williams D, Davison J. BMJ 2008;336:211-215Barua M et al. Clin J Am Soc Nephrol 2008;3:392-396
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Pregnancy and dialysis
As much dialysis as you can facilitate and certainly >20 hours/week
Maintain pre-dialysis urea < 15mmol/l
How much?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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0
5
10
15
20
25
Dia lys is Transplant (Bel fast)
Conc
eptio
n ra
te (p
er 1
000
wom
en/y
ear) Fertility returns
within 1 -2 monthsof transplant
Transplant and pregnancy
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Renal disease and pregnancy – renal transplant
Pregnancy outcomes following transplant are
vastly better than if still on dialysis
- 95% success
General guidelines1. Wait 2 years post-transplant (some say 12-18 months)
2. Stable renal function
3. Minimal proteinuria
4. Minimal or well-controlled hypertension
5. No transplant rejection
6. Minimal levels of appropriate immunosuppression
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Renal disease and pregnancy – renal transplant
Pregnancy outcomes are predicted
by baseline kidney function
Baseline creatinine Complicated pregnancy
Successful outcome
<125 μmol/l 30% 97%
>125 μmol/l 82% 75%
Persistent post pregnancy kidney function
impairment develops in 15% of transplant patients
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Renal disease and pregnancy – renal transplant; children
Children born to mothers with a renal
transplant do well in general
Complications are due mainly to
preterm delivery and low birth weight
Overall, 16% of children have specialeducational needs (cf. 11% in USA general population)
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Transplant dysfunction in pregnancy
• Same causes• Same investigations (caution but not contraindication to
radiation exposure)
• Different treatment
Infection Rejection Obstruction Medication
Biopsy if indicated.
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Drugs
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Drugs, CKD and pregnancy
• Altered pharmacodynamics
• Potential teratogenicity
Check the BNF
Learn what you can use
ImmunosuppressantsAntibioticsAntihypertensives
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Drugs, CKD and pregnancy
Antihypertensives
1. Labetalol2. Methyldopa3. Nifedipine4. Hydralazine
1. ACE inhibitors2. ARBs
3. Spironolactone4. Aliskiren
5. Moxonidine6. Minoxidil7. Diltiazem
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Drugs, CKD and pregnancy
Antibiotics
1. Cephalosporins2. Penicillins3. Gentamicin4. Erythromycin
1. Quinolones2. Tetracyclines
1. Trimethoprim(not in 1st trimester)2. Nitrofurantoin(not in 3rd trimester)
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Drugs, CKD and pregnancy
Immunosuppressants
1. Prednisolone2. Cyclosporine3. Tacrolimus4. Azathioprine
1. Mycophenolate mofetil2. Mycophenolic acid
3. Sirolimus4. Methotrexate
5. Cyclophosphamide6. ATG / OKT3
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Rock and roll
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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