Pregnancy and kidney disease: case studies
38
Pregnancy and kidney disease: case studies Matt Hall May 28 th 2009
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Pregnancy and kidney disease: case studies. Matt Hall May 28 th 2009. Why is it important to know about pregnancy and kidney disease?. It’s means a lot for a small number of people. It can be very scary if you don’t know what you’re doing. It’s in the exam. Loads!. - PowerPoint PPT Presentation
Transcript of Pregnancy and kidney disease: case studies
Pregnancy and kidney disease: case studies
Matt Hall
May 28th 2009
Why is it important to know about pregnancy and kidney disease?
1. It’s means a lot for a small number of people.
2. It can be very scary if you don’t know what you’re doing.
3. It’s in the exam. Loads!
What do you need to know?
Blood pressure and treatment
Serum creatinine Presence of UTI
ProteinuriaPast obstetric
history
Medication
Management interventions
Treat bloodpressure
Aspirin
LMWH
Deliver baby
Treat infection
Dialysis
Case 1
• Age 34. Primigravida.
• Renal transplant 2001 – ESRD ?cause
• Attended pre-conception counselling 4 months before conception
Case 1 - baselineBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 100/60 on no Rx prior to conception
Creatinine 122μmol/l (eGFR 44ml/min), stable
No history of recurrent UTI
PCR 23 mg/mmol creatinine
Not applicable
Prednisolone, tacrolimus, azathioprine
Case 1 – at booking
Didn’t realise she was pregnant until 22 weeks
Case 1 – 24 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 162/102
Creatinine 90μmol/l
No UTI
PCR 66 mg/mmol creatinine
Not applicable
Prednisolone, tacrolimus, azathioprine
Methyldopa
Case 1 – 28 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 139/84
Creatinine 103 μmol/l
No UTI
PCR 69 mg/mmol creatinine
Not applicable
Prednisolone, tacrolimus, azathioprine, methyldopa
Case 1 – 32 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 141/83
Creatinine 95 μmol/l
No UTI
PCR 115 mg/mmol creatinine
Not applicable
Prednisolone, tacrolimus, azathioprine, methyldopa
Case 1 – 35 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 118/82
Creatinine 112 μmol/l
No UTI
PCR 138 mg/mmol creatinine
Not applicable
Prednisolone, tacrolimus, azathioprine, methyldopa
Case 1 – 37 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 139/84
Creatinine 121 μmol/l
No UTI
PCR 69 mg/mmol creatinine
Not applicable
Prednisolone, tacrolimus, azathioprine, methyldopa
Case 1 – 39 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 149/95
Creatinine 141 μmol/l
No UTI
PCR 111 mg/mmol creatinine
Not applicable
Prednisolone, tacrolimus, azathioprine, methyldopa
Induction
Outcome
Weight: 3.25kgApgar: 101 and 105
Status: Alive and well
Outcome
0
10
20
30
40
50
60
70
16/12/0
2
16/06/0
3
16/12/0
3
16/06/0
4
16/12/0
4
16/06/0
5
16/12/0
5
16/06/0
6
16/12/0
6
16/06/0
7
16/12/0
7
16/06/0
8
16/12/0
8
eGFR
(ml/
min
)
Acute rejection
Case 2
• 23 year old. Primigravida.
• Type 1 DM.
• Retinopathy.
Case 2 – baselineBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP ?: no Rx
Creatinine 84μmol/l (eGFR 78 ml/min)
No history of recurrent UTI
Not recorded – no known h/o proteinuria
Not applicable
Insulin, lamotrigine Aspirin
Case 2 – 20 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 107/62: no Rx
Creatinine 85μmol/l
No UTI
PCR 331 mg/mmol creatinine
Not applicable
Insulin, lamotrigine, aspirin LMWH
Case 2 – 22 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 121/69: no Rx
Creatinine 85μmol/l
No UTI
4.14g/24h. Albumin 32g/dl. Oedema.
Not applicable
Insulin, lamotrigine, aspirin, LMWH
Case 2 – 28 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 126/82: no Rx
Creatinine 71 μmol/l
No UTI
5.53g/24h. Albumin 33g/dl.
Not applicable
Insulin, lamotrigine, aspirin, LMWH
Case 2 – 34 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 104/65: no Rx
Creatinine 77 μmol/l
No UTI
PCR 683 mg/mmol. Albumin 32g/dl.
Not applicable
Insulin, lamotrigine, aspirin, LMWH
Case 2 – 37 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 119/71: no Rx
Creatinine 81 μmol/l
No UTI
PCR 622 mg/mmol. Albumin 34g/dl.
Not applicable
Insulin, lamotrigine, aspirin, LMWHInduction at38 weeks
Outcome
Weight: 3.32kgApgar: 91 and 95
Status: Alive and well
Outcome
0
100
200
300
400
500
600
700
800
05/1
2/20
07
05/0
1/20
08
05/0
2/20
08
05/0
3/20
08
05/0
4/20
08
05/0
5/20
08
05/0
6/20
08
05/0
7/20
08
05/0
8/20
08
05/0
9/20
08
05/1
0/20
08
05/1
1/20
08
05/1
2/20
08
05/0
1/20
09
PCR
(mg/
mm
ol c
reati
nine
)
Outcome
0
20
40
60
80
100
120
26/0
3/20
07
26/0
4/20
07
26/0
5/20
07
26/0
6/20
07
26/0
7/20
07
26/0
8/20
07
26/0
9/20
07
26/1
0/20
07
26/1
1/20
07
26/1
2/20
07
26/0
1/20
08
26/0
2/20
08
26/0
3/20
08
26/0
4/20
08
26/0
5/20
08
26/0
6/20
08
26/0
7/20
08
26/0
8/20
08
26/0
9/20
08
26/1
0/20
08
26/1
1/20
08
26/1
2/20
08
26/0
1/20
09
26/0
2/20
09
Crea
tini
ne
Case 3
• 29 year old. G2 P1+0
• IgA nephropathy diagnosed following first pregnancy
Case 3 - baselineBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 105/70 prior to conception
Creatinine 91μmol/l (eGFR 66ml/min)
No history of recurrent UTI
PCR 175 mg/mmol creatinine
Nephrotic from 20 weeks.Pre-eclampsia at 35 weeks.
Ramipril
Case 3 – 10 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 144/90
Creatinine 85μmol/l
No UTI
PCR 393 mg/mmol creatinine but 1.9g/d. Albumin 29 g/dl
Nephrotic from 20 weeks.Pre-eclampsia at 35 weeks.
Case 3 – 12 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 150/99 but good 24h BPM
Creatinine 85μmol/l
No UTI
PCR 353 mg/mmol creatinine. Albumin 28 g/dl
Nephrotic from 20 weeks.Pre-eclampsia at 35 weeks.
LMWH
Case 3 – 22 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 132/85
Creatinine 103μmol/l
No UTI
PCR 241 mg/mmol. Albumin 27 g/dl
Nephrotic from 20 weeks.Pre-eclampsia at 35 weeks.
LMWH
Case 3 – 27 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 138/87
Creatinine 123 μmol/l
No UTI
PCR 444 mg/mmol. Albumin 23 g/dl
Nephrotic from 20 weeks.Pre-eclampsia at 35 weeks.
LMWH
Case 3 – 32 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 127/76
Creatinine 107 μmol/l
No UTI
PCR 680 mg/mmol. Albumin 22 g/dl
Nephrotic from 20 weeks.Pre-eclampsia at 35 weeks.
LMWH
Evidence of poor fetal growth
Admit3x/wk visits
Case 3 – 34 weeksBlood pressure and treatment
Serum creatinine
Presence of UTI
Proteinuria
Past obstetrichistory
Medication
BP 131/71
Creatinine 125 μmol/l
No UTI
PCR 708 mg/mmol. Albumin 25 g/dl
Nephrotic from 20 weeks.Pre-eclampsia at 35 weeks.
LMWHElective CSat 35+5/40
Outcome
Weight: 1.75kgApgar: 91, 105
Status: Alive and well
Outcome
0
50
100
150
200
250
300
350
Crea
tinin
e
Renal biopsy
Summary
• Stats say that adverse maternal and fetal outcome depends on:– blood pressure– baseline creatinine
• Patients don’t often read the stats
Summary
Treat bloodpressure
Aspirin
LMWH
Deliver baby
Treat infection
http://renal.pinetreeavenue.com
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