The document discusses renal disease in pregnancy, describing acute kidney injury (AKI) and chronic kidney disease (CKD) that can occur. It covers the causes, classification, clinical presentation, and treatment approaches for AKI during pregnancy, which can be difficult to diagnose due to normal physiologic changes. Management involves treating the underlying condition, supportive care including fluid management, and potentially dialysis in severe cases.

1. Renal Disease in Pregnancy
By:
Sita Chhetri
Women Health Development
(MN)
Charak Academy Pvt. Ltd.

2. Normal Physiologic Alterations of
Pregnancy

3. Acute Kidney Injury (AKI)
• AKI is known as prompt decrease in renal function
over a period of several hours to days sufficient
enough to result in retention of nitrogenous waste
products in body.
• The physiological changes in pregnancy make
diagnosis of AKI difficult.
It is also known as acute renal failure (ARF)

4. AKI Contd…
ARI is suspected in the following conditions:
• Oliguria: (urine output of <30 ml/hour or <400 ml/24
hrs
• Anuria
• Deteriorating renal function as demonstrated by rising
serum creatinine
(Creatinine level ≥1 mg/dl of rapid rise (in 48 hrs) of
0.5 mg/dl above baseline

5. Incidence
• More common problem in the developing nation but
lesser incidence due to the improvement in antenatal
care and the reduction of septic abortion due to its
legalization
• Socioeconomic factors contributing to PRAKI in the
underdeveloped countries are mainly due to poverty,
poor obstetrics care, lack of proper healthcare
facilities and awareness of the condition, delayed
referral process, multiparity, and the increasing
population number.

6. Incidence Contd..
• The rate of PRAKI in Canada increased from 1.6 per
10 000 deliveries in 2003 to 2.3 per 10 000 deliveries in
2007.
• United States : rate increased from 2.3 to 4.5 per
10 000 deliveries over a 10-year period between 1998
and 2008
• The reason for the growing rate of PRAKI, that is
possibly not actual incidence, might be due to the
increasing sensitivity of AKI diagnosis with close
obstetric observation, particularly in high risk
pregnancy. Moreover, the incidence of dialysis required
PRAKI also declined.

7. Classification of AKI (KDIGO)
(The Kidney Diseases: Improving Global
Outcomes)
Stage Serum creatinine concentration Urine output
criteria
1 SCr 1.5-1.9 times baseline OR
≥26.5 ummol/L (0.3 mg/dL)
increase
<0.5 ml/kg/h for 6-
12 hrs
2 SCr 2-2.9 times baseline <0.5 ml/kg/h for 6-
12 hrs
3 SCr 3 times baseline OR Initiation
of renal replacement therapy OR In
pts <18 yrs, decrease in GFR to
<35ml/min/1.73m2
Anuria for ≥12 hrs

8. RIFLE Classification of AKI
(The Acute Dialysis Quality Initiative
(ADQI) group)

9. Contd…
• Unfortunately, the mentioned definition of AKI is not
valid for pregnant women due to the physiological
changes during pregnancy

12. Causes
Early in pregnancy
Prerenal cause
• Hyperemesis
gravidiaum
• Hemorrhage
-Abortion
-Ruptured ectopic
pregnancy
• Sepsis
-Septic abortion
Pregnancy being
associated with
heightened
inflammation, changes
to vascular
endothelium, and a
prothrombic state, is
more likely to favor the
development of ATN

13. Causes Contd…
Hperemesis gravidarum
• Present in first trimester of pregnancy with acute
renal failure associated with a hypovolemic,
metaolic allkalosis.
Abortion
• Is an infected abortion complicated by fever.
Endometritis and parametritis and it remains one of
the most serious threats to woman's health.

14. Causes Contd…
Third trimester and postpartum period
Prerenal causes
– APH (placenta abruption)
– PPH
Intrarenal causes
– Severe pre-eclampsia
– HELLP Syndrome
– Acute fatty liver of pregnancy
– Thrombotic microangiopathies

15. Causes Contd…
Preeclampsia : major cause of renal dysfunction during
pregnancy.
• It is accompanied by a specific renal lesion known as
glomerular endotheliosis, in which the glomruli enlarge
and become ischemic.
• Characterized by general vasoconstriction and
hemoconcentration with a reduced intravascular volume.

16. Causes Contd…
HELLP
• Is a syndrome characterized by hemolysis, elevated
liver enzymes and low platelet count/
• 5-10% of women with pre-eclampsia develop
HELLP
• AKF occur in up to 40% of women with HELLP
syndrome
• ARF may be a result of direct renal injury or as a
consequences of abruption.

17. Causes Contd…
Acute Fatty Liver of Pregnancy
• It is defined as microvesicular fatty infiltration of
hepatocytes during second half of pregnancy, and it
remains a common cause of liver failure in pregnancy
• It is associate with ARF in up to 60% of cases.
• There is decreased renal perfusion or acute tubular
necrosis (ATN).

18. Causes Contd…
Thrombotic Microangiopathies
• Combination of thrombocytopenia and
microangiopathic anaemia.
• Rare and affect 1 per 25000 pregnancies
• Presence of fibrin and/ or platelet thrombi in the
microcirculation of multiple organs. (most affected
organ: brain or kidney)
• Clinical entities described:
Thrombocytopenic purpura (TTP)
Hemolytic uremic syndrome (HUS)

19. Causes Contd…
• TTP: is characterized by fever, thrombocytopenia,
micronagiopathic hemolytic anaemia, mild renal
failure (creatinine <1.4mg/dl) and neurologic
symptoms (disorientation, ataxia, headache, focal
changes, seizures or aphasia)
• HUS: occasionally develops as a complication of
preeclampsia. Featurs of HUS are similar, but
neurological involvement is rare while renal
involvement is profound (creatinine>2.3mg/dl).

20. Others Causes
Nephrotoxic Drugs
• NSAIDs when given to the mother peripatrum,
reduce renal blood flow and can cause acute renal
impairment to both mother and fetus.
• Women with reduced intravascular volume,
especially if they have pre-existing renal
impairment.
• Indomethacin may also precipitate hyperkalemia.

21. Others Contd…
Post-operative Oliguria
• It is usually secondary to hypovolemia from
hemorrhage , although renal function may also be
depressed by general anaesthesia.

23. Comparing Clinical Characteristics of
AKI

24. Renal disease.docx
Differentiating features of severe
preeclampsia, HELLP syndrom,
AFLP, TTP and HUS

25. AKI treatment in Pregnancy
• There are 3 aspects to consider in the management of
AKI related to pregnancy
1. Renal function supportive measures
2. Treatment of underlying disease
3. Dialysis

26. Treatment Contd…
1.Renal function supportive measures
• Etiological treatment, suspension of nephrotoxic
drugs or treatment of an infectious disease should be
started as soon as possible.
• Administration of IV fluids to restore and maintain
renal perfusion also prevents hypovolemia and
ensures an adequate uteroplacental perfusion and fetal
well-being.

27. Treatment Contd…
• Pharmacologic therapy of AKI and its known
complications: hypertension, hyperkalemia, metabolic
acidosis and anemia.
• Antihypertensive drugs: first-line treatment options in
pregnant women are methyldopa and labetalol
• Hyperkalemia : should be promptly corrected using
glucose/insulin or potassium-binding resins such as
polystyrene sulfonate.
• Anemia: blood transfusion is recommended in acute
therapy. The erythropoiesis-stimulating agents are safe in
pregnancy, but higher doses are usually required to obtain
the desired therapeutic effect.

28. Treatment Contd…
2. Treatment of the underlying disease
i. Unsafe abortion
Prevention of unwanted pregnancy and avoidance of septic
abortion are key to eliminate abortion associated AKI in early
pregnancy .
Fluid therapy: should start immediately and larger amounts
may be needed but must be done with careful monitoring to
ovoid overload.

29. Treatment Contd…
• Antimicrobial therapy: IV antibiotics should be
started as early as possible always within first hour or
recognizing sepsis
• Blood product administration: if coagulopathy
develops

30. Treatment Contd…
ii. Hyperemesis
• Fluid and electrolyte replacement.
• Avoid dextrose containing fluids which may precipitate
wernicke’s encepahopathy.
• Withhold non—essential drug associated with nausea and
vomiting as iron supplementation
• A combination of antiemetic medications may be required

31. Treatment Contd…
Preeclampsia /HELLP
• Delivery for oliguria or a rise in serum creatinine from normal
to >1.3mg/dl
• In case of hypovolumia, severe creatinine 1.0-1.36 mg/dl, and
no clinical signs of pulmonary edema- fluid challenges.
• CVP monitoring: in case of serum creatinine >1.36mg/dl,
refractory HTN, or multisystem organ failure
• IV hydralazine or low dose dopamine infusion (2.5
ug/kg/mim) if necessary.
• Furosemide infusion (5 mg/hr) and fluid restriction if
necessary.
• Continue invasive central hemodynamic monitoring until the
diuretic phase in postpartum.
• Corticosteroid : used to accelerate fetal lung maturity followed
by delivery after 24 hrs.

32. Treatment Contd…
AFLP
• It is important to confirm diagnosis because women with AFLP
can rapidly develop liver failure and encephalopathy.
• Admit to ICU. Invasive hemodynamic monitoring may be
necessary.
• Maternal stabilization condition glycemic control with glucose
administration and coagulopathy correction with fresh frozen
plasma, BT or cryoprecipatitate is essential.

33. Treatment Contd…
AFLP
• Hepatic encephaopathy is treated with low protein diet and
oral lactulose.
• Delivery should be induced immediately to avoid progression
to liver failure.
• Monitor clotting, hypoglycemia and fluid balance before and
after delivery.
• Temporary dialysis occasionally.

34. Treatment Contd…
• TTP and HUS sharing overlapping features and may be difficult to
differentiate from each others.
TTP
• Differentiate from pre-eclampsia
• Plasma infusion may be first-line approach in case with less severe
thrombocytopenia.
• Plasmapheresis is preferable in cases with severe hematologic
manifestations
• Anti platelet therapy (aspirin, dipyridamole) in conjunction with plasma
exchange.

35. Treatment Contd…
• Immunosuppressive therapy (prednisone,
cyclophosphamide, vincristine or rituxmab) or
splenectomy, or both, for non responders to plasma
exchange.
• Consider delivery at 34 weeks.

36. Treatment Contd…
HUS
• Dialysis for most cases
• Red cell transfusion for severe anemia
• Plasma exchange and prednisone until 4 wks
postpartum

37. Treatment Contd…
2. Dialysis : if the previous procedures prove to be
insufficient , dialysis is the next step
Indication
• Electrolyte imbalance especially hyperkalemia
• Metabolic acidosis
• Volume overload
• Symptomatic uremia
-Pericarditis
-Neuropathy
-Mental status changes

38. Treatment Contd…
• Dialysis should be initiated when the serum creatinine level is
3.5-5.0 mg/dL or the glomerular filtration rate (GFR) is below
20 ml/min.

39. Chronic Renal Disease

40. Introduction
• Chronic Kidney Disease (CKD) is an umbrella term that
describes irreversible kidney damage or a decrease in the
GFR for three or more months.
• Gradual and usually permanent loss of kidney function
occurs over time, usually months to years.
• CKD is associated with decreased quality of life,
increased health care expenditures, and premature death.
• Untreated CKD can result in ESRD and necessitate renal
replacement therapy.

41. Introduction Contd…
• CKD leads to:
disturbed excretion of end products of metabolism
disturbed elimination of electrolytes and water
disturbed secretion of hormones(eg. Erythropoietin, renin,
prostaglandins, active form of vitamin D)

42. Classification
• Mild renal insufficiency : serum creatinine of 1.3mg/dl
or less
• Moderate renal insufficiency :serum creatinine of 1.3 to
1.9 mg/dl
• Severe renal insufficiency: serum creatinine of 1.9mg/dl
or greater.
• Chronic renal insufficiency is characterized by oliguria
or anuria requiring dialysis

43. Staging of CKD (KDIGO)
GFR categoties in CKD
GFR category GFR (ml/min/1.73
m2)
Terms
G1 >90 Normal or high
G2 60-89 Mildly decreased
G3a 45-59 Mildly to
moderately
decreased
G3b 30-44 Moderately to
severely decreased
G4 15-29 Severely decreased
G5 <15 Kidney failure

45. Staging of CKD according to National Kidney
Foundation
• Stage 1: Kidney damage with normal kidney function (estimated
GFR ≥90 mL/min per 1.73 m2) and persistent (≥3 months)
proteinuria.
• Stage 2: Kidney damage with mild loss of kidney function
(estimated GFR 60-89 mL/min per 1.73 m2) and persistent (≥3
months) proteinuria.
• Stage 3: Mild-to-severe loss of kidney function (estimated GFR 30-
59 mL/min per 1.73 m2).
• Stage 4: Severe loss of kidney function (estimated GFR 15-29
mL/min per 1.73 m2).
• Stage 5: Kidney failure requiring dialysis or transplant for survival.
Also known as ESRD (estimated GFR <15 mL/min per 1.73 m2).

46. Epidemiology
• Fertility is substantially decreased in women with GFRs less
than 50%
• Eighty five percent of women with renal disease will have a
surviving infant
• Worsening renal function is directly correlated with pre
pregnancy creatinine.
• One- third of women with pre-existing moderate to severe renal
insufficiency will develop end stage renal disease within 1 year
of delivery
• Uncontrolled hypertension is the single most important indicator
of poor pregnancy outcome
• Women with renal disease requiring dialysis, 2% of hemodialyis
will conceive over a 4 year period versus 1% women treated
with peritoneal dialysis

47. Etiology
• Most common cause are
 Diabetes mellitus-33%
 Hypertension- 24%
 Glumerulonephritis -17%
 Ploycystic kidney disease – 5%
• The etiologies that have been associated with worsening of
renal disease in pregnancy are:
 Membrano proliferative glumerulonephritis
 Reflux nephropathy
 Immunoglobulin nephropathy
 Focal sclerosis

48. Pathophysiology
• Impairment of acid-base regulation predispose the fetus to
acidemia
• Inadequate blood pressure control is associated with a dismal
obstetric prognosis
• Hypertension secondary to renal disease places the fetus at risk
due to:
 Uteroplacental insufficiency
 Decreased perfusion
 Decreased oxygen availability

50. Clinical Features
• Urinary- Polyuria, Oliguria, Anuria
• Cardiovascular – Hypertension, pitting odema, engorged
neck veins, Pericardial effusion, uremic pericarditis,
• Integumentary; Dry, pale skin, severe pruritus, ecchymosis,
thin brittle nails, uremic frost ( rare).
• Pulmonary; Tenacious sputum , depressed cough reflex,
shortness of breath, kussmaul’s respiration, pleuritic pain,
uremic pluritis.
• Neurological : Weakness and fatigue, confusion, Inability to
concentrate, Disorientation, seizures and coma.

51. Clinical Features Contd…
• Musculoskeletal: Muscle cramp, loss of muscle strength
• Gastrointestinal: metallic taste, anorexia, nausea and
vomiting, constipation, bleeding from GI, weight loss, uremic
fetor ( urinous odor of breath).
• Hematological: Anemia, Bleeding tendency
• Reproductive: Infertility, decreased libido, amenorrhea in
female, sexual dysfunction.
• Psychological changes: Personality and behavioral changes,
withdrawal, depression

52. Evaluation
• Baseline 24 hrs urine collection for protein and creatinine
clearance should ne obtained and repeated monthly.
• Nephrotic – range proteinuria is most commonly due to
precclampsia in women with underlying renal disease.
• The appearance of worsening proteinuria is common but
does not necessarily portend worsening of renal function.
• Baseline serum creatinine with repeated assessment at
regular intervals.

53. Evaluation Contd…
• Baseline blood pressure with home monitoring
• Prenatal visit at least twice monthly.
• Targeted ultrasound at 18 to 20 weeks followed by monthly
sonogram to assess for fetal growth restriction.
• Antepartum fetal testing were starting at 32 weeks of gestation
or earlier if severe hypertension, preeclampsia or other
specific complication occurs.

54. Management
1. Pre pregnancy counseling
• Women should be counseled by a multidisciplinary
team as fertility, as well as pregnancy outcome,
depends on the degree of renal insufficiency.
A discussion about
– risks of pre-eclampsia,
– fetal growth restriction
– preterm delivery
– about the long-term risks to their own health
– risk of deterioration in renal function following
pregnancy.

55. Pre pregnancy counseling Contd..
• Single embryo transfer should be recommended to
women undergoing in vitro fertilization. This is the
ideal opportunity to establish baseline renal function
and achieve optimal control of hypertension.
• ACE inhibitors and angiotensin receptor blockers are
contraindicated in pregnancy. They do, however,
provide significant renal protection and hence the
current recommendation is to change over to safer
drugs after the woman becomes pregnant.

56. 2. Medical Management
• Hypertension: Beta blockers, calcium channel
blockers and hydralazine.
• Amaemia: ferrous sulfate, erythropoietin and /or
transfusion

57. 3. Obstetric management
• More frequent hospital visits, depending on the clinical
situation.
• Regular scans are recommended every 4 weeks from 28 weeks
of gestation onwards to check growth as well as liquor
volume.
• Consideration should be given to prophylactic low dose aspirin
for the prevention of pre-eclampsia.
• Blood pressure monitoring and adequate control are important.

58. 3. Obstetrical Management Contd…
• Preterm labour is common. The prompt treatment of
bacterial vaginal and urinary tract infections,
including asymptomatic bacteriuria, can be helpful
for prevention of preterm labour.
• Women with recurrent urinary tract infections should
be given antibiotic prophylaxis throughout pregnancy.

59. Obstetrical Management Contd…
In the absence of maternal or fetal deterioration,
• Delivery should be planned at or near term.
• Early delivery is usually necessary for
 obstetric indications such as pre-eclampsia and fetal growth restriction
or
 for rapidly deteriorating maternal renal function.
• Obstetric considerations should be the main determinant for
caesarean section.
• Women with nephrotic syndrome should receive prophylactic
heparin in pregnancy as well as for 6 weeks postpartum.

60. Management
Referral /Counseling
Nephrology consultation for management

61. Outcome
Maternal outcome
• Pregnancy, when it occurs in women with CKD, is considered
high risk.
• Pregnancy is rare when serum creatinine rises beyond 3 mg/dl as
either these females have amenorrhea or have anovulatory cycles.
In case if pregnancy does occur in these women about a third will
progress to ESRD in 1 year post partumigh risk.
• Nephrotic proteinuria is common. There may be increase in
maternal mortality and increase in the incidence of cesarean
deliveries.

62. Outcome Contd…
Fetal outcome
• Spontaneous abortion and intrauterine growth retardation is
frequent.
• Full-term delivery is less common and stillbirth and low birth
weight are higher in women with CKD stages 3 and 4.
• Live birth rate varies with the stage of CKD and is 98% in
mild renal failure and 90% in those with moderate renal failure
while those with severe renal failure have 50% fetal loss.
(Sahay,2015).

63. Patient Education
Patient must be educated regarding
– The risk of pregnancy and worsening renal function or
resultant end stage renal disease within 1 year of delivery.
– Recommendation for termination if renal function and
blood pressure acutely worsen in the first trimester.
– The need for intensive monitoring throughout the
pregnancy to optimize maternal and fetal outcome.

64. References
Arun, J. (2017). AKI during pregnancy, pregnancy-related acute
kidney injury, acute renal failure in pregnancy. Retrieved from
www.clinicaladvisor.com › Decision Support in Medicine › Critical
Care Medicine.
Evansm A.T., & DeFranco,E. (2015). Manual of obstetris (2nd ed.).
India: Wolters kluwer.
Edmonds, K. (2012). Dewhurst’s textbook of obstetrics and
gynaecology (8th edition). London: Willey blackwell.
James., Steer., Weiner., Gonik., Croether., & Robson. (2012). High risk
pregnancy management option (4th ed.). India: Elsevier.

65. References Contd…
Kapoor , N.,Makanjuola , D., & hehata, S. (2008). Management of women
with chronic renal disease in pregnancy. Retrieved from
http://onlinetog.org.
• KDIGO (2012). KDIGO Clinical practice guideline for acute kidney injury.
Journal of the international society of nephrology, 2(1)
Krane, N. K. (2015). Renal Disease and Pregnancy. Retrieved from
emedicine.medscape.com/article/246123-overview.
Machado, S., Figueiredo, N., Borges, A., Pais, M.S., Freitas, L., Moura., &
Campos, M. (2012). Acute kidney injury in pregnancy: a clinical
challenges. 25 (1)). Doi: 10.5301/jn.5000013.
• Michael Hnat, M., & Sibai, B.M. (2008). Renal Disease and Pregnancy.

66. References Contd…
• The Global Library of Women's Medicine.
doi:10.3843/GLOWM.10157.
• Sahay, M. (2015). Pregnancy in chronic kidney disease. Indian
journal of nephrology. 25 (4). doi:10.4103/0971-4065.147768.
• Seshadri, L., & Arjun, G. (2016). Essentials of obstetrics (2nd
ed.). India: Wolters kluwer.