Effect of pregnancy on the kidney Increased plasma volume Increased intravascular volume Increased GFR Increased intraglomerular pressure Hyponatremia is frequently seen Hypokalemia can be seen

Pregnancy and renal disease Hormonal changes contribute to these

changes Pregnant ladies gain 12 to 16 kilograms of

weight mostly fluids Serum creatinine and BUN decreases in

pregnancy Normal serum creatinine can be a sign of a

significant renal disease Pregnancy affect renal disease and renal

disease affect the outcome of pregnancy

Pregnancy and renal disease Pregnancy is associated in a decline in renal

function in 1 -- 10% of cases when GFR is mildly reduced at the beginning of pregnancy Cr less than 1.5 mg/dl

The rise in Cr is seen at the third trimester Transient decline in renal function may be seen

Moderate renal impairment Women with moderate renal

insufficiency ( Cr between 1.5 and 2.9 mg/dl )

In these patients there is a decline of Cr in the first trimester but rise above base line level as the pregnancy progress

0

0.5

1

1.5

2

2.5

76 women with pregnancy and moderate renal impairment

First trimester 3rd trimester

Jones etal New Eng J 1996 335 : 226

Some patients may have permanent decline in renal function

In the previous study 10% of the women progressed to end stage renal disease

The risk was highest in patients with a serum Cr above 2 mg/dl

The risk of permanent decline in renal function is highest in the presence of uncontrolled hypertension

Once serum creatinine exceed 3 mg /dl most women have amenorrhea or anovulatory cycles making the likelihood of pregnancy very small

Some studies showed some link between the type of renal disease and outcome being worse in MPGN and reflux nephropathy

Effect of kidney disease on pregnancy Fetal survival is lowest with uncontrolled

hypertension The relative risk of fetal death tenfold

higher in women with a mean blood pressure greater than 105 mmHg

The risk of prematurity is increased when serum creatinine exceed 1.4 mg/dl

Preterm delivery is not uncommon

There is an increased risk of pre-eclampsia with increased fetal and maternal morbidity

Pre-eclampsia might be more difficult to diagnose in the presence of baseline proteinuria and hypertension

In this situation worsening of proteinuria and hypertension might be a clue to the diagnosis

Pregnancy in the dialysis patient The frequency of conception in this

group is .3 to 1.5 % per year There is increase fetal wastage in this

group

Blood pressure and anemia may become more difficult to control in this group

Hou an his group surveyed 1281 women of childbearing age on dialysis

1.5% became pregnant over tow years time

52% had surviving infants

02468

101214161820

total no

surviving infants

Hou,SH pregnancy in women on dialysis AM J Kid Dis 1994 23 60

Survivng infants

Total no

Pregnancy and dialysis Bogan in Belgium surveyed 1472

women of child bearing age on dialysis

1.5% became pregnant over tow years time

50% had successful out come of pregnancy

Bagon etal pregnancy and dialysis Am J of Kid disease 1998 , 31 ; 766

Dialysis and pregnancy There is improvement in the survival

compared to old reports because of More intense dialysis with BUN below 17

mmol/l 50 mg/dl ( almost daily dialysis )

Higher dose of EPO is required to provide adequate red cell mass

Metabolic acidosis and hypocalcaemia should be corrected

Pregnancy and dialysis Careful uterine and fetal monitoring during

dialysis and through out the whole pregnancy

Avoid hypotension during dialysis since this may provoke uterine contraction and fetal loss

Nutritional status and dry weight should be assessed on frequent bases since intradialytic weight gain can be confused with the usual weight gain in pregnancy

Dialysis and fetal size In spite of optimal therapy mothers

are at increased risk of sever hypertension and premature delivery with a mean gestational age of 30 weeks

If the patient is a good potential candidate for transplant it is better to delay pregnancy tell she is transplanted

Case presentation A 24 year old saudi lady found to

have raised creatinine when she was evaluated for primary infertility and a diagnosis of ESRD was made

Her renal function continued to deteriorate and she was put on regular hemodialysis

A cadaver transplant was done

Case presentation The transplant was successful and her

serum Cr was around 1.2 mg/dl She was maintained on azathioprine

steroids and cyclosporine She became pregnant 18 months post

transplant with a full term twins Serum Cr post delivery was 1.3 mg One year later her serum Cr was 1.4 She became pregnant

Case presentation Hb before gestation was 9.4 gm Hb decreased to 7.8 gm with more

symptoms EPO was added and her anemia

improved with Hb of 11 at the time of delivery

The outcome of the pregnancy was successful

Erythropoietin Therapy in a Pregnant Post-Renal Transplant PatientSaad Al ShohaibDepartment of Medicine, King Khalid National Guard Hospital, Jeddah, Kingdom of Saudi Arabia

Address of Corresponding AuthorNephron 1999;81:81-83 (DOI: 10.1159/000045251)

Renal transplant Fertility return after transplant with a

pregnancy success rate of more than 90% after the first trimester

There is slight increase in spontaneous abortion and intrauterine growth retardation

Pregnancy has no important early effect on renal function and affected by the same factors in pregnancy in patients with renal impairment

Renal transplant Women are advised to wait one year after

living related transplant and tow years post cadaver transplant to avoid complications arising from rejection

Neither low dose prednisolone or azathioprine appear to have adverse effect on the fetus

The obstetrician should review the operative notes to confirm the location of the graft

cyclosporine Cyclosporine may aggravate or induce

hypertension during pregnancy Cyclosporine does not appear to be a

major teratogen Cyclosporine metabolism is increased

during pregnancy and higher doses may be required to achieve adequate levels however there is controversy regarding adjusting the dose

Mycophenolate mofetil MMF should not be used in pregnancy

as animal studies showed adverse effect on the fetus

Patient that are welling to get pregnant should be converted to azathioprine

Sirolimus (Rapamycin ) Sirolimus is contraindicated in

pregnancy and should discontinued at least 12 weeks prior to pregnancy

Cyclosporine should be used during gestation but once delivered sirolimus can be restarted

Tacrolimus (prograf ) Kains reviewed 100 pregnancies in

84 women treated on prograf 27% were renal transplant recipients 68% progressed to alive birth Four babies had malformations

Obstetrical mangement Increase frequency of prenatal visit Early treatment of a symptomatic

bacteriuria Monthly renal function Close monitoring for the development

of pre eclampsia

SLE SLE occur frequently in women in

child bearing age SLE patients are usually as fertile as

other patients but their pregnancy is associated with more complication

The prognosis is best for both the mother and fetus if SLE is quiescent for at least 6 months

SLE

Exacerbation of the disease Fetal loss Neonatal lupus Breast feeding

Exacerbation of the disease

50% of patients will exacerbate their disease during pregnancy

Flares occur in all three trimester and in the immediate postpartum period

Ruiz prospectively evaluated 40 pregnancies in 37 patients with SLE

Flare up occurred in 24 cases 60%

Compared to the rates of flare up post delivery the rate is higher

Flare up mainly as nephritis and arthritis

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30

35

40

sle

Ruiz etal increased rate of lupus flare up during pregnancy Br J Rheum 1996 35:133

Lupus nephritis There is increased risk of fetal loss Increased risk of worsening renal

function as well as other manifestations of the disease

Sever renal impairment requiring dialysis may occur

Pre existing hypertension and azotemia are associated with worse prognosis

SLE following transplant The outcome is similar to other

transplant patients

Comparison between SLE and Non SLE post renal transplant pregnancy outcome

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30

40

50

60

70

80

SLE 60

non LSE376

Live birth

abortion

Therapeutic termination

Mccy Groy etal pregnancy outcome Am J Transp 2003 3:35

pre eclampsia and SLE Preeclampsia is a frequent

complication of SLE 13% It might be difficult to distinguish

between preeclamsia and lupus nephritis

Active urinary sediment is suggestive of lupus nephritis

P

Pre eclampsia and SLE Complement C3 C4 are low in lupus

nephritis but normal in preeclamsia Anti DNA titer is increased in lupus

nephritis Thrombocytopenia and raised liver

enzymes are suggestive of preecalmpsia

Fetal loss and SLE risk factors Hypertension Lupus nephritis Low C3 high DNA Antiphospholipid antibody

Fetal loss and SLE

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5

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15

20

25

SLE control control

fetal loss

Petri etal fetal outcome of lupus pregnancy J Rheum 1993 20 650

Hypertension and pregnancy Preeclamsia eclampsia Chronic hypertension (present before

20 weeks of pregnancy Preeclampsia superimposed on

underlying hypertension Gestational hypertension

(hypertension in after 20 weeks without prteinuria

Hypertension preeclampsia Labetalol is the is the preferred

therapy for sever hypertension Hydralazine is an acceptable

alternative Methyldopa and labetalol the first line

oral therapy Atenolol should be avoided in early

pregnancy

Hypertension and pregnancy ACE inhibitors and ARBs are

contraindicated during pregnancy since uterine and placental ischemia may occur

Nitroprusside should be avoided (fetal cyanide poisinig)

Breast feeding Beta blockers and calcium channel

blockers enter breast milk but are safe during lactation

ACE inhibitors and ARBs should be avoided

Diuretics reduce milk volume and should be avoided

Preexisting hypertension Has a strong on fetal and maternal

outcome Preeclampsia 10– 20% Preterm birth 12—34% Growth retardation 8—16% The higher the blood pressure the

worse the outcome

ARF in pregnancy HUS TTP HELLP syndrome Renal cortical necrosis Acute pyelonephritis Acute fatty liver of pregnancy

Thank you