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Renal Disease and Pregnancy

Renal Disease and Pregnancy. Matt Hall Nottingham Renal Unit SpR Club Belfast. Sex Drugs Rock and roll. Sex. Pregnancy and CKD. ?. National Statistics Online. Conception statistics 2008. http://www.statistics.gov.uk/downloads/theme_health/conceptions2008/conceptions08.pdf

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Renal Disease and Pregnancy

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  1. Renal Disease and Pregnancy Matt Hall Nottingham Renal Unit SpR Club Belfast

  2. Sex Drugs Rock and roll

  3. Sex

  4. Pregnancy and CKD ? National Statistics Online. Conception statistics 2008. http://www.statistics.gov.uk/downloads/theme_health/conceptions2008/conceptions08.pdf Brown JH, Maxwell AP, McGeown MG. Irish J Med. 2001 Barua M, Hladunewich M, Keunun J et al. Clin J Am Soc Nephrol. 2008;3:392/396

  5. Pregnancy and CKD Approximate number of pregnancies per year in UK

  6. Maternal and fetal risks Maternal risks Is pregnancy going to make my kidney disease worse? Fetal risks Will I take home a healthy baby?

  7. Maternal and fetal risks

  8. Factors associated with adverse outcomes Baseline renal function?

  9. Baseline renal function?

  10. Baseline renal function?

  11. Baseline renal function? p=0.027

  12. Baseline renal function? * * ** **

  13. Factors associated with adverse outcomes Baseline renal function - yes Baseline blood pressure?

  14. Blood pressure?

  15. Blood pressure? p=0.08 p=0.009

  16. Blood pressure? • 43 pregnancies in 30 women with CKD (serum creatinine 110 to 490 μmol/l) • Hypertension was present from conception in 26 (60%). • Logistic regression identified uncontrolled hypertension at conception as an independent risk factor for fetal death • RR fetal death with MAP> 105mmHg at conception = 10.5 • Accelerated loss of maternal renal function in 7 patients, all of whom had hypertension • 168 pregnancies in 118 women with IgA nephropathy. • Perinatal mortality 33% in women with BP>140/90 versus 1% with BP<140/90 • (Hypertension not identified as a risk factor for progression of maternal disease.) Jungers P et al. Pregnancy in women with impaired renal function. Clin Nephrol 1997;47(5):218-288 Abe S. Pregnancy in IgA nephropathy. Kidney International 1991;40:1098-1102

  17. Factors associated with adverse outcomes Proteinuria ? Baseline renal function - yes Baseline blood pressure - yes

  18. Proteinuria X Second trimester ACR>3mg/mmol Women without CKD OR 1.9 preterm delivery Second trimester ACR>20mg/mmol OR 4.7 preterm delivery Diabetes and hypertension Proteinuria > 3g/d Women with CKD Creat > 124μmol /l No impact on outcome Proteinuria < 3g/d Pregnancy (n=19) Women with CKD Proteinuria and pregnancy assoc with PALRF No pregnancy (n=31) Franceschini N et al. Maternal urine albumin excretion and pregnancy outcome. Am J Kindy Dis. 2005’45(6):1010-1018 Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. New Engl J Med 1991;336(4):226-223 Hemmelder MH et al. Proteinuria: a risk factor for pregnancy-related renal function decline in primary glomerular disease? A,m J Kidney Dis 1995;2691):187-192

  19. Proteinuria? Imbasciati E et al. AJKD 2007;49:753

  20. Proteinuria?

  21. Proteinuria p=0.60 p=0.03 p=0.86

  22. Factors associated with adverse outcomes Proteinuria maternal? no fetal? yes Baseline renal function - yes Baseline blood pressure - yes Aetiology of kidney disease?

  23. Aetiology of kidney disease? No convincing evidence of effect of aetiology on outcomes

  24. Aetiology of kidney disease? SLE Renal dysfunction Antiphospholipid syndrome Anti-Ro antibodies Hypertension Medication All associated with adverse outcomes Not the “SLE” label itself

  25. Aetiology of kidney disease? Reflux nephropathy Increased risk of UTI Neonatal morbidity and mortality Preterm labour Maternal mortality Increased risk of pyelonephritis

  26. Aetiology of kidney disease? Diabetes

  27. Aetiology of renal disease?

  28. Factors associated with adverse outcomes Baseline renal function - yes Proteinuria maternal? no fetal? yes Baseline blood pressure - yes Aetiology of kidney disease – not really

  29. Management of CKD and hypertension in pregnancy Masterful inactivity Hawk-like observation

  30. Management of CKD in pregnancy Preconception counselling Limited interventions Pre-eclampsia prophylaxis Medicines management Blood pressure control Thrombo- prophylaxis Urinary tract infection treatment Dialysis manipulation Immunosuppressant tweakage Timing of delivery

  31. Management of CKD and hypertension in pregnancyPre-eclampsia prophylaxis

  32. Management of CKD and hypertension in pregnancyPre-eclampsia prophylaxis Aspirin 75mg od Systematic review 37560 women All women High risk women 17% relative risk reduction 25% relative risk reduction NNT = 72 NNT = 19 Perinatal death RRR 14% Preterm delivery RRR 8% SGA RRR 10% Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst.Rev. 2007 Apr 18;(2)(2):CD004659.

  33. Not evidence based Different practices between (and within) centres. Management of CKD and hypertension in pregnancyThrombo-prophylaxis Nephrotic syndrome RR VTE = 1.7 Pregnancy RR VTE = 4.3 ? Heavy proteinuria RR VTE = ? Pregnancy RR VTE = 4.3

  34. Management of CKD and hypertension in pregnancyThrombo-prophylaxis Add-up risk factors Prophylactic LMWH No treatment If renal impairment, monitor Factor Xa levels Low threshold for investigating suspected VTE Treat until 6 weeks postpartum

  35. Management of CKD and hypertension in pregnancyUrinary tract infection Pyelonephritis Asymptomatic bacteruria 4x increased risk in pregnancy 21% risk of progression if untreated Treatment of asymptomatic bacteruria in pregnancy reduces the incidence of pyelonephritis by 75%

  36. Management of CKD and hypertension in pregnancyUrinary tract infection …Antibiotic treatment of asymptomatic bacteruria is indicated to reduce the risk of pyelonephritis in pregnancy… …Antibiotic treatment of asymptomatic bacteruria was associated with a reduction in the incidence of low birth weight babies (RR 0.66 (0.49-0.89))… Based on studies from 1960-1970s

  37. Management of CKD and hypertension in pregnancyUrinary tract infection n=85,484 Pyelonephritis Asymptomatic bacteruria Non-pyelonephritic UTI Preterm birth 8.3% Preterm birth 7.7% Preterm birth 7.2% Small for gestational age 18.9% Small for gestational age 16.5% Small for gestational age 16.1% After adjusting for confounding covariates, no increased risk of preterm birth or small infant in women exposed to urinary tract infection. Chen YK et al. Acto Obstet Gynecol Scand 2010;89(7):882-888

  38. Management of CKD and hypertension in pregnancyUrinary tract infection In pregnancy Asymptomatic bacteruria Non-pyelonephritic UTI Treat Pyelonephritis Second or more episode in pregnancy? Asymptomatic bacteruria Non-pyelonephritic UTI Treat Prophylaxis Pyelonephritis

  39. Management of CKD and hypertension in pregnancyBlood pressure control

  40. Management of CKD and hypertension in pregnancyBlood pressure control Do not treat to DBP<80mmHg Target BP <150/100 Chronic hypertension Target BP <140/90 Chronic hypertension + CKD Target BP ? and treat with what? Chronic hypertension + proteinuric CKD

  41. Management of CKD and hypertension in pregnancyBlood pressure control Target BP <140/90 Chronic hypertension + proteinuric CKD

  42. Pregnancy and dialysis ? National Statistics Online. Conception statistics 2008. http://www.statistics.gov.uk/downloads/theme_health/conceptions2008/conceptions08.pdf Brown JH, Maxwell AP, McGeown MG. Irish J Med. 2001 Barua M, Hladunewich M, Keunun J et al. Clin J Am Soc Nephrol. 2008;3:392/396

  43. Pregnancy and dialysis An average sized renal unit in the UK would expect to treat one pregnant patient on dialysis every four years

  44. Pregnancy and dialysis How do you diagnosis pregnancy in a woman on dialysis? Amenorrhoea? Pregnancy test from Boots?

  45. Pregnancy and dialysis How do you diagnosis pregnancy in a woman on dialysis? Intradialytic hypotension? Serum βhCG Early ultrasound Elevated Serum βhCG but no fetal heart beat? Serial βhCG Repeat ultrasound in 1-2 weeks

  46. Pregnancy and dialysis

  47. Pregnancy and dialysis Befriend an obstetrician • Fetal growth monitoring every 1 – 2 weeks • Liquor volume monitoring every 1 -2 weeks • CTG monitoring every dialysis session from 25 weeks

  48. Pregnancy and dialysis PD? Yes! • Conception rates may be lower • Infection rates no higher • No contraindication to Caesarean

  49. Pregnancy and dialysis HD? Yes! How much?

  50. Pregnancy and dialysis

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