Assosiated with SGA , IUD, premature labour, Hypertension and anemia
Persistant leukocyturia (2-3 wbc/HPF)
Significant bacteriuria 10 5
10 2 with symptoms
70% have asymptomatic bacteriuria
Mostly in second trimester
Symptoms – Pain, fever, dysuria
Complication – Endotoxic Shock, DIC, ARF
IV Antibiotics for 24 – 48 hours
Change to oral antibiotics for 10-14 days
Symptoms – Urgency, frequency and dysuria without systemic signs
Culture may be negative
Recurrence is 17%
Usually doesnot progress to pyelonephritis
30% will progress to pyelonephritis
Increases risk of premature labour and low birhtweight
Repeat culture in high risk patient ( repeated UTI and anomalies) Treatment : Cephalosporins for 3-7 days (pyelonephritis risk reduced to 3%) Recheck culture after 2-3 weeks ( recurrence 35%) 2 or more repeated infection Supressive therapy with nitrafurantoin and cephalosporins
Safety of antibiotics category Antibiotic A. Drugs taken by large no of pregnant women with out any proven harm Amox, ampi,cefalexin, Cephalothin,nitrofurantoin,penicillin B1 Taken by limited no of pregnant women with out proven harm; animal studies show no increase in fetal harm Aztreonam, ceftazidime,cefataxime, cefaclor, amox/clavulanic acid,piperacillin B2 As B1, but animal data unavailable Vancomycin B3 As B1,but animal studies show an increase in fetal damage Cipro, norfloxacin, ofloxacin,imipenem, Trimethoprim C Drugs whose pharmalogic effects are suspected of causing harm Sulphonamides, Cotrimoxazole, fusidic acid D Proven to cause fetal harm Tetracycline, gentamycin, Chloramphenicol
New onset hypertension(140/90mmhg) & proteinuria after 20 weeks( PC ratio 0.3 μ g/ mg creatinine)
Uric acid >5.5mg/dl
wide spread endothelial dysfunction and
micro angio pathy in mother
Severe preeclampsia BP 160/110 Urine PC ratio >5 μ g/mg or proteinuria >5g/24 h urine Oliguria CVA , seizures, visual disturbance Pulmonary edema Epigastric or rt upper quadrant pain Hepato cellular injury Sr LDH >600 iu/l Thrombocytopenia < 100000(HELLP syndrome) IUGR
Proteinuria and hypertension usually will disappear within days or weeks, sometimes may take maximum of six months
Renal Biopsy – Proteinuria for more than six months , Deteriorating renal function, Presence of Urinary Sediments
Predicts future hypertension 7-37% and future cardiovascular risk
75-80 mg Aspirin
Vit C and E do not protect
Weight loss & salt restriction not recommended
Anti hyper tensive
ACE inhibitors& ARB contraindicated .
Diuretics should be used carefully .
Alfa methyl dopa is the drug of choice.
Hydralazine is drug of choice in emergencies.
β blockers can be used.
CCB may cause tocolysis in third trimester
Management of preeclampsia PROBLEM MANAGEMENT Control blood pr Acute Rx if BP >170/110 Chronic Rx if BP>140/90 Eclampsia Diazepam 10-20mg to terminate convulsion Magnesium sulfate for neurological sign 4 g IV over 20 minutes then 1.5 g/hr for 48 hrs Volume expander therapy 500-1000 ml of colloid over 4-6 hr for persistent oliguria Supportive therapy Platelet infusion if count <20000-40000 FFP for micro angiopathy Dialysis for ARF Progressive decline in renal, hepatic or clotting function or fetal growth Delivery
Type of hyper tension drug Rx given Acute Hydralazine 5 mg bolus every20- 30 min (max 20 mg) then infusion at 5-10 mg/hr Labetolol 50 mg 20 every min (max 300mg) Nifidipine 20 mg oral Chronic first line Methyl dopa 500-2000mg/day PO Clonidine 0.2-0.8 mg /day PO Labetolol 200-1200mg/day PO Atenolol 50- 100 mg/day PO Second line Hydralazine 25-200 mg/day PO Prazosin 1-10 mg/day PO Nifidipine sr 40-100 mg/day PO
Acute renal failure in pregnancy
Renal failure in early pregnancy
Hemorrhage associated with spontaneous abortion
Acute tubular necrosis
Severe volume depletion (hyperemesis gravidarum, hemorrhage from spontaneous abortion, or shock secondary to septic abortion )
Renal Cortical Necrosis
The disorder is most likely initiated by primary disseminated intravascular coagulation in the setting of severe renal ischemia
It is more commonly associated with pregnancy.
C/F- gross hematuria, flank pain, and severe oliguria/anuria following an obstetric catastrophe (abruptio placentae, septic abortion, retained fetus, amniotic fluid embolism).
The diagnosis can usually be confirmed by demonstrating a radiolucent rim in the cortex , using computed tomography (CT) scanning.
Recovery typically requires months, and renal functional recovery is usually incomplete.
Thrombotic thrombocytopenic purpura(TTP)
While TTPand hemolytic uremicsyndrome represent a spectrum that includes microangiopathic hemolytic anemia, thrombocytopenia, and renal failure, TTP is more likely to occur in the first trimester and generally does not cause severe renal failure.
Patients may have a severe deficiency of ADAMTS-13.
Plasma exchange is the primary treatment
Renal failure in late pregnancy
Preeclampsia and the associated disorders (eclampsia and HELLP)
Acute tubular necrosis
Uterine hemorrhage with abruptio
Acute fatty liver of pregnancy
Acute fatty liver of pregnancy
c/f- abdominal pain and jaundice, typically occurring after week 34 of gestation.
Bilirubin is elevated, with mild elevations of aspartate aminotransferase and alanine aminotransferase levels also occurring. Severe cases can present with fulminant hepatic failure.
The disorder is commonly associated with acute renal failure .
Noninvasive imaging can also provide evidence of fatty liver.
Pathogenesis- microvesicular fatty infiltration of hepatocytes, which may related to defective mitochondrial beta-oxidation of fatty acid
Rx- Immediate delivery and supportive care. Most patients fully recover
Postpartum renal failure
Hemolytic uremic syndrome
severe hypertension, microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure.
Postpartum acute renal failure usually presents days to weeks following a normal delivery and may be related to retained placental fragments
Hemolytic uremic syndrome can be difficult to differentiate from severe preeclampsia or HELLP syndrome and may require renal biopsy for diagnosis(presence of schistocytes may be help ful)
Other causes of acute renal failure in pregnancy
moderate or severe dilatation of the collecting system in women with oliguria or anuria
Etiologies of obstructive uropathy include gravid uterus, polyhydramnios, kidney stones, and enlarged uterine fibroids.
Obstructive uropathy usually resolves with delivery, although ureteral stenting may be required preterm .
All pregnant women with lupus should be screened for antiphospholipid antibodies and lupus anticoagulant.
These women are at increased risk for fetal loss and worsening of renal function .
Treatment with low-dose aspirin or heparin depends on antibody levels and previous obstetric history of early fetal loss and/or thrombo
Restoration of fluid nvolume
Delivery of baby as early as possible
DIALYSIS – individualised
- sr. creatinine ≥3.5 mg/dl
20 % of normal pregnancy
Ig A Nephropathy
Polycystic Kidney Disease
Sickle cell trait
Hemorrhagic bacterial cystitis
More than 300mg/day or Urine PC ratio 0.3 mg per milligram of creatinine
New Onset glomerular disease
May be due to infection or contamination of Vagina
Decrease risk of calcium stone
Though calciuria/ dilatation/ stasis, there is increased excretion of inhibitor of stone formation( magnesium, citrate, nephrocalcin)
Decreased risk of uric acid &cystine stone
due to gestational bicarbonateamia and alkalanisation of urine
Xanthine oxidase and d-pencillamine avoided especially during Ist trimester
preterm rupture of membranes
UTI-Management : treatment for longer period followed by antibiotic prophylaxis
Ultrasonography is the primary diagnostic imaging modality .
Ureteral stenting may be necessary if the stones cannot be passed.
PREGNANCY WITH PRE-EXISTING KIDNEY DISEASE Effects on Renal disease Effects on Pregnancy outcome RENAL FUNCTION: Mild: Serum creatinine < 1.4 GFR >50 ml/min Mild/ no deterioration of renal function Preterm labour Moderate: Serun Creatinine 1.5-1.9 GFR 25-50ml/min 40% decline in renal function, but 50% will have recovery 2%----ESRD Preterm labour Preeclampsia IUGR Severe: Serum Creatinine >2 GFR <25ml/min 2/3----rapid decline 1/3-----ESRD Preterm labour Preeclampsia IUGR
Cont… Effects on Renal Disease Effects on Pregnancy Outcome PROTEINURIA >500mg /24hr urine
Risk for chronic hypertension
Poor long term renal prognosis
Preterm labour Preeclampsia IUGR HYPERTENSION >Rapid decline in renal function Preterm labour Preeclampsia IUGR Increased perinatal mortality ( from 4% t 23 %) UTI Pyelonephritis Preterm Labour Low Birth Weight REDUCED PLASMA VOLUME IUGR HYPERGLYCAEMIA Large for gestational age
MANAGEMENT OF WOMEN WITH CKD DURING PREGNANCY PREPREGNANCY Advise- Increased risk of Pregnancy complications |( IUGR, Preeclampsia,pretem labour) Adivise – increased risk of deteriorating maternal renal function Discontinue inappropriate medication- STATINS, ACE INHIBITORS, ARB Aspirin 75 m/dl Folic acid 5 mg/dl
Urine |Culture every 4-6 weeks- after one infection , keep urine sterile with prophylactic antibiotics
Proteinuria more than 3g/24hr-thrombosis prophylaxis with LMW heparin
Proteinuria 1-3g/24hr- prophylaxis if other risk factors ( smoking , matrenal age> 35 yrs, obesity, immobilty)
Haematuria- if red cell cast suggesting active parenchymal disease, consider renal biopsy or delivery if > 32 weeks
Blood Pressure – maintain BP at or below 140/90 mm Hg with antihypertensive medication
Serum Creatinine, BUN- recognise acute or chronic renal impairment and need for dialysis
FBC and iron status’-use iron or EPO if necessary to keep Hb 10-11g/dl
HD regimen to mimic physiological renal changes of pregnancy
after first trimester increase dialysis regimen to almost daily( 20-24hrs per week) to keep predialysis BUN < 50 mg/dl, serum urea< 17 mmol/L
Increase EPO and Iron to keep Hb 10-11g/dl
Recognise gestational weight gain, approximately 0.5kg/week in 2 nd and 3 rd trimster
Recognise hypertension might be caused by fluid overload before using anti-hypertensive medication
Give Aspirin 75 mg and Folic acid 5mg daily throughout pregnancy.
Adjust phosphate binders and vitamin D according to serum chemistry
Aim for protein intake 1.2 to 1.8 g/kg/day
LABOUR AND DELIVERY
Cesarean Section most likely
Women on PD will need temporary HD ( for 72 hours)
Close monitoring of BP and Fluid balance
Gradually return to non-pregnant dialysis regimen over 2 weeks
Advise to delay pregnancy until 2 years post-transplantation
Advise of increased risk of adverse pregnancy outcome according to BP, proteinuria and GFR
Discontinue and substitute inappropriate medications including statins, ACE inhibitors , ARB, mycophenolate and sirolimus
Aspirin 75 mg once daily
Folic acid 5mg daily
Keep maintenance CNIs at lower end of therapeutic levels
Be aware of the dilutional fall in CNI levels in pregnancy
Monitor BP, renal function, Proteinuria and urine culture every 4-6 weeks throughout pregnancy
MANAGEMENT OF RENAL TRANSPLANT RECEPIENTS DURING PREGNANCY
peri-partum prophylactic antibiotics
Spontaneous vaginal delivery, usually possible despite pelvis kidney
Temporary increase in steroid dose to cover the stress of delivery
re-adjust CNIs dose
Breastfeeding while taking azathioprine and cyclosporine unlikely to be harmful but should probably be limited to < one month
Clinical parameters like Hypertension/proteinuria/ development of renal impairment/ UTI more important than histological type
sudden renal impairment with serum creatinine >1.4 mg/dl
New onset heavy proteinuria ( >5g/24hrs)
Active urinary sediment with red cell cast (32 weeks)
Ig A Nephropathy
Women with normal renal function&BP have successful uncomplicated pregnancy
Pre-existing HT- risk factor for pre-eclampsia and fetal prematurity
High risk for recurrent proteinuria/Hypertension during pregnancy
Pregnancy has triggered recurrent HSP
Deteriorating renal function
Increased fetal mortality
2. Antenatal period
Urine culture every 4-6 weeks throughout pregnancy
3. Women with persistent VUR should be corrected befire planning for pregnancy .
Upper Urinary Tract Obstruction
Renal function assessment
Urine culture and BP
USG -at end of first trimester
repeat if symptoms of infectionor rise in sr creatinine occurs
The best outcomes occur in women who have had stable, inactive lupus for 6 months or longer prior to conception.
Renal flares in pregnancy usually present with proteinuria, hypertension, and falling GFR, making distinction from preeclampsia very difficult. Low complement levels may be helpful in distinguishing between women with preeclampsia and patients with active lupus nephritis.
These patients should all be screened for anti-SSA, due to the risk of congenital heart block
low dose steroids
relapse- iv methyl prednisolone 500mg daily for 3 days
increased oral prednisolone
low dose aspirin
peripartum flare up - steroids
Pregnant women with diabetic nephropathy may also develop worsening proteinuria and hypertension
Complication - preeclampsia
good control of blood glucose & blood pressure before and during pregnancy improves perinatal & maternal out come
Guidelines for pregnancy in kidney transplant recipient:
Two years posttransplant, with good general health and serum creatinine less than 2.0 mg/dL (preferably <1.5 mg/dL)
No recent or ongoing rejection
Normotension, or minimal antihypertensives
Absent or minimal proteinuria
No evidence of pelvicalyceal dilation on renal ultrasonogram