Reflux Nephropathy

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Reflux Nephropathy

  1. 1. A Case of Reflux Nephropathy A difficult case
  2. 2. Mrs LC <ul><li>Transferred from Pendlebury aged 17 in Feb 1991 </li></ul><ul><li>Initially presented with renal failure aged 12 </li></ul><ul><li>Renal transplant in 1989 </li></ul><ul><li>Had some “early problems” but well at that time (creat 149) </li></ul><ul><li>Renal function deteriorated (creat 260) and she was treated for infection. </li></ul><ul><li>Biopsy showed cyclosporin nephrotoxicity. </li></ul><ul><li>Her function was stabilised and she continued with follow up as usual. </li></ul>
  3. 3. Problems begin <ul><li>Noted on several letters in 1991-1992 that her weight and blood pressure was low. </li></ul><ul><li>In 1992 she went down to 5 stone & was referred to psychiatry with anorexia. </li></ul><ul><li>At that time her attendance was sporadic. </li></ul><ul><li>July 92 – E coli UTI </li></ul><ul><li>Aug 92 – 2x admission with UTI </li></ul><ul><li>March 93 – UTI </li></ul><ul><li>Commenced on prophylactic antibiotics. </li></ul><ul><li>Aug 93 – admitted with UTI & urogenital HSV </li></ul><ul><li>Creatinine remains stable at 192. </li></ul>
  4. 4. Baby Boom <ul><li>Commenced on Oral Contraceptive pill </li></ul><ul><li>Risks of pregnancy discussed </li></ul><ul><li>Rick of cervical cancer discussed. </li></ul><ul><li>No further UTI’s for a reasonable time. </li></ul><ul><li>April 1994 – referred to Obstetrician at Preston for close supervision of first pregnancy </li></ul><ul><li>Pt aware of increased risk of pre-eclampsia </li></ul><ul><li>Aware cyclosporin may increase risk of in-utero growth retardation. </li></ul><ul><li>Creatinine 168 at this time </li></ul>
  5. 5. A bouncing baby girl <ul><li>The pregnancy proceeded without major complication </li></ul><ul><li>Elective caesarean performed since pt 5ft tall and breech presentation </li></ul><ul><li>Healthy Child delivered Nov 1994 </li></ul><ul><li>Post natal creatinine 168 </li></ul><ul><li>Persistently low cyclosporin levels and poor compliance. </li></ul><ul><li>July 1996 – creat increased to 240 </li></ul><ul><li>Biopsy showed acute rejection + cyclosporin toxicity </li></ul><ul><li>Further episode Pyelonephritis </li></ul><ul><li>Creat improved to 170 by september </li></ul>
  6. 6. The patter of tiny feet….. <ul><li>Became pregnant in sept 1996 </li></ul><ul><li>3 UTI’s during pregnancy </li></ul><ul><li>Admitted at 33 weeks – hydramnios </li></ul><ul><li>Personal problems & struggled with tiredness </li></ul><ul><li>Healthy girl delivered in april 1997 </li></ul><ul><li>Post partum creat 141 </li></ul><ul><li>Advised not to risk further pregnancy </li></ul><ul><li>Episodes of UTI over next few years. </li></ul><ul><li>Declined investigations to assess for ongoing reflux </li></ul><ul><li>Pregnant again in Nov 2000 (creat 133) </li></ul>
  7. 7. Little bundles of joy…. <ul><li>Another girl delivered april 2001 </li></ul><ul><li>Uneventful pregnancy and delivery </li></ul><ul><li>Post natal creat 157 </li></ul><ul><li>Sterilisation recommended </li></ul><ul><li>2 further UTI’s </li></ul><ul><li>Pregnant again in March 2002 </li></ul><ul><li>Delivered early as developed ureteric obstruction Nov 02 </li></ul><ul><li>Post natal creat 170 </li></ul><ul><li>Fourth girl – found to have reflux </li></ul>
  8. 8. Screening and problems <ul><li>Child 4 has reflux and so others are screened. </li></ul><ul><li>Child 2 also found to have reflux ( now aged 6) </li></ul><ul><li>Child 4 has major problems due to tracheomalacia </li></ul><ul><li>Mrs LC now struggling with 4 children aged 0-8 </li></ul><ul><li>Neglecting herself while child 4 has regular admissions to hospital. </li></ul><ul><li>Creatinine declines rapidly: 209 Jan 03 </li></ul><ul><li>396 june 03 </li></ul><ul><li>921 Aug 03 </li></ul><ul><li>Biopsy shows allograft nephropathy </li></ul><ul><li>High dose steroids tried </li></ul>
  9. 9. Things come to a head <ul><li>Admitted August with symptomatic uraemia </li></ul><ul><li>Restarted dialysis via temporary line </li></ul><ul><li>UTI’s continued </li></ul><ul><li>Grand mal seizures – EEG abnormal therefore commenced valproate </li></ul><ul><li>Major social issues </li></ul><ul><li>Now back on maintenance Haemodialysis programme </li></ul><ul><li>Problems with access but fistula successfully formed jan 04 </li></ul><ul><li>Back on transplant list. </li></ul>
  10. 10. Issues <ul><li>Multiple difficulties faced by young people with renal transplants </li></ul><ul><li>Ongoing problems with recurrent UTI can exist after transplantation </li></ul><ul><li>Pregnancy may be a risk in all patients with renal failure </li></ul><ul><li>Caring for a large family has an impact on an individuals health </li></ul><ul><li>Reflux nephropathy is potentially hereditary. </li></ul>

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