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
2.5
First trimester
3rd trimester
2
1.5
1
0.5
0
76 women with pregnancy and moderate renal impairment
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 preeclampsia 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
20
18
16
Total no
14
12
10
survivin
g infants
8
6
4
2
0
total no Survivng infants
Hou,SH pregnancy in women on dialysis AM J Kid Dis 1994 23 60
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
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 Patient
Saad Al Shohaib
Department of Medicine, King Khalid National Guard
Hospital, Jeddah, Kingdom of Saudi Arabia
Address of Corresponding Author
Nephron 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
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
40
evaluated 40
35
pregnancies in 37
30
patients with SLE
25
 Flare up occurred
in 24 cases 60%
20
 Compared to the
15
rates of flare up
10
post delivery the
5
rate is higher
0
 Flare up mainly as
nephritis and
arthritis
Ruiz etal increased rate of lupus flare up during pregnancy
sle
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
Live birth
80
70
60
50
40
30
20
10
SLE 60
abortion non LSE
376
Therapeutic termination
0
Mccy Groy etal pregnancy outcome Am J Transp 2003 3:35
pre
eclampsia and SLE
P
 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
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
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

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Hypertension
Lupus nephritis
Low C3 high DNA
Antiphospholipid antibody
Fetal loss and SLE
25
20
15
fetal loss
10
5
0
SLE
control
control
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
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HUS TTP
HELLP syndrome
Renal cortical necrosis
Acute pyelonephritis
Acute fatty liver of pregnancy
Thank
you