THE RENAL DISEASES IN THE KIDNEY

BY

PRAYTHIESH BRUCE(CRRI)

DEPT OF OBG,SMIMS

KULASEKHARAM

OVER VIEW

Introduction Urinary tract infection Acute pyelonephritis Chronic pyelonephritis Acute renal failure Pregnancy in renal transplant patient Hypertension and renal disease

INTRODUCTION

Diseases of urinary tract is common in pregnancy-structural and functional changes are normally seen in pregnancy

STRUCTURAL CHANGES: Dilatation of urinary tract-iii trimester

Stasis,hydronephrosis occur- due to gravid uterus and dilatation of right side ureter occur-due to dextrorotation uterus

Progesterone-relaxant-smooth muscle

FUNCTIONAL CHANGES IN PREGNANCY

Renal blood flow-increases by 80% Gfr,creatinine,creatinine clearance-increases

by 50% >0.9%mg/dl s.creatinine suggest renal

disease Glycosuria-lowering of renal threshold Sodium and water retention Fall in osmolality

URINARY TRACT INFECTION

Commonest infection Causative organism; Ecoli Klebsiella Pseudomonas aeroginosa TYPES A)asymptomatic bacteruria B)cystitis C)acute pyelonephritis

ASYMPTOMATIC BACTERURIA Occur in 5%pregnancy Must be treated as 30%can cause

symptomatic infection Diagnosis: First visit:screening by urine culture and

microscopy Routine mid stream urine culture of

>1,00,000organisms per 1 ml (Len)leucocyte esterase nitrate dip stick test

can be used if prevalence is low in the population

TREATMENT OF ASYMPTOMATIC BACTERURIA

Treatment required to prevent pyelonephritis/preterm delivery

It is associated with risk of hypertension,preeclampsia,anaemia in mother and lbw in children

Treatment depend on culture sensitivity report

TREATMENT OF ASYMPTOMATIC BACTERURIA(3-5)DAYS

Oral antibiotics: Ampicillin 500mg qid Amoxycillin 5oomg tds Cephalexin 250mg tds Nitrofurantoin 100mg qid Iv antibiotics: Cefuroxime 750 mg tds Coamoxyclav 1.2g tds

CYSTITIS Infection of lower urinary tract Characterised by burning micturition( dysuria) Frequency Urgency Complicate in 1% pregnancy

CYSTITIS CAUSATIVE ORGANISM

Ecoli Klebsiella Pseudomonas aeroginosa DIAGNOSIS: Urine analysis shows Bacteriuria,pyuria,hematuria Urine culture and sensitivity

TREATMENT FOR CYSTITIS

Depend on culture sensitivity report Oral antibiotics: Nitrofurantoin 100mg qid Ampicillin 500mg qid Amoxycillin 500mg tds Cephalexin 250mg tds

Infection of upper urinary tract involving both renal pelvis and parenchyma

Incidence- 1-2% Causative organism; Ecoli Klebsiella Pseudomonas aeroginosa

ACUTE PYELONEPHRITIS

CLINICAL FEATURES OF ACUTE PYELONEPHRITIS

Onset is acute, 2nd &3rd trimester of pregnancy Symptoms: Anorexia, back pain , chills & rigor with fever,

dysuria, nausea & vomiting Signs: Increased temprature(101of) Urine turbid Tachycardia

INVESTIGATIONS FOR ACUTE PYELONEPHRITIS

Urine examination: High specific gravity, acid reaction,

proteinuria, leucocytes, red cells, white cell cast,bacteria

Urine culture & sensitivity test: Blood examination: sign of renal dysfunction,

elevated bun, creatinine & creatinine clearance

COMPLICATIONS OF ACUTE PYELONEPHRITIS

Septic shock due to endo-toxins Pulmonary injury Chronic renal infections Adult respiratory distress syndrome Abortion, fetal growth restriction,intra-uterine

fetal death Premature labour

TREATMENT OF ACUTE PYELONEPHRITIS

Hospitalisation, bed rest, plenty of fluids, easily digestable diet, pulse oximetry

4th hrly TPR & B.P monitoring Uterine contractions, fetal monitoring, I.V.F for dehydrated & oliguric patients

(crystalloids,dextrose, D.saline) I/V antibiotics Ampicillin 500mg iv 6th hrly Co amoxyclav 1.2g iv 12 hrly after patient is afebrile

for 24-48 hrs oral antibiotics started

CHRONIC PYELONEPHRITIS

Chronic diseases charecterised by severe scarring of the kidneys resulting from persistent/ recurrent infections in patients with vesico-urethral reflux

Complications : Chronic hypertension Acute pyelonephritis Chronic microcytic anaemia Pre-eclampsia, hyponatraemia, glycosuria

TREATMENT OF CHRONIC PYELONEPHRITIS

Maternal & fetal prognosis depends on the extent of the renal damage

Cap. Ampicillin 500mg/tab.nitrofurantoin 100mg/cap. Cephalexin 500mg -1cap. Every night for the duration of pregnancy

ACUTE RENAL FAILURE

Rare complication in pregnancy in which sudden decrease in renal function with oliguria over a period of hours or days

Diagnosis: Oliguria, hyperkalemia, metabolic

acidosis,rising blood urea &creatinine

CAUSES OF ACUTE RENAL FAILURE

Obstetric haemorrhage Infection Septic abortion Pre eclampsia Drugs-nsaids Renal diseases Post renal(obstructive uropathy)

TYPES OF ACUTE RENAL FAILURE

ACUTE TUBULAR NECROSIS

RENAL CORTICAL NECROSIS

Less serious serious

Reversible Irreversible

a/w sepsis & htn a/w obstetric causes& pre-eclampsia

Kidney lesion- focal, dilatation & flattening of epethelium of DCT,pigmented cast in lower part of nephrons

Kidney lesion- focal,patchy confluent/gross resulting from thrombosis of renal vascular system

TYPES OF ACUTE RENAL FAILURE

ACUTE TUBULAR NECROSIS

RENAL CORTICAL NECROSIS

Patint have high grade temperature, vomiting, diarhoea

Oliguria which can lead to anuria, azotoemia &consumptive coagulopathy

Shock occurs rapidly & may have mild jaundice, pallor& cyanosis

Extra-renal manifestations like cardic dilatation, CHF, lethargy, convulsions

Most patient respond to volume resuscitation &vigorous antibiotics in ICU

_

CLINICAL FEATURES OF ACUTE RENAL FAILURE

Oliguria- sign of acute impaired renal function Input /output chart Patient is warm to touch, thirsty, irritable,

lethargic Rise in blood urea &serum potassium level

which causes muscular & ECG changes In diuretic phase there is excess of passage

of urine, but blood urea remains high

MANAGEMENT OF ACUTE RENAL FAILURE Early diagnosis is important Blood volume replacement is required for hemorrhage,

control of B.P& delivery for pre- eclampsia, stoppage of nephro-toxic drugs

Patient needs intensive care with hydration Assessment of fluid balance by C.V.P line is important Liberal fluids given in hemorrhagic shock Infection should be controlled by antibiotics in septic

abortion & puerperal sepsis Blood levels of electrolytes, urea, creatinine should be

checked daily Help of nephrologist is sought Peritoneal/hemodialysis is performed to keep BUN to

50mg/dl If not already delivered, delivery should be expedited after

stabilising her general condition

PREGNANCY IN RENAL TRANSPLANT PATIENT

More women are expected to come for pregnancy with more liberal use of renal transplant

They should delay pregnancy for 1-2 years after transplantation to allow the graft function to stabilise &immunosupperession reach maintenance level

Cyclosporine, azathioprine, prednisolone are considered safe in pregnancy

Women on Cyclosporine should not breast feed

CHRONIC RENAL DISEASE IN PREGNANCY

Incidence: 0.2% Effect of pregnancy on kidney disease:Effect of pregnancy on kidney disease:

Mild Moderate Severe

Risk of renal failure is low (<5%)

Risk of renal failure is 10%

Risk of renal failure is 50%

Serum creatinine <125 micromol/lit

Serum creatinine 125-250 micromol/lit

Serum creatinine >250 micromol/lit

Super-imposed pre-eclampsia prognosis is worse

Primary glomerulo-nephritis has better prognosis

Focal glomerulo sclerosis, immune nephropathy, membrano-proliferative glomerulo-nephritis has poor prognosis

Effect of kidney disease on Effect of kidney disease on pregnancypregnancy

Effect of pregnancy depends upon the severity of Effect of pregnancy depends upon the severity of renal diseases, serum creatinine levels, renal diseases, serum creatinine levels, hypertension & proteinuriahypertension & proteinuria

Super-imposed pre-eclampsia- perinatal mortality is 50%

In severe kidney disease risk of abortion, IUGR, pre-term labour

Careful pregnancy surveillance, proper treatment, improved neonatal care& colaboration with nephrologist has improved prognosis of mother & newborn

TREATMENT OF CHRONIC RENAL DISEASE IN PREGNANCY

Pre-conceptional counselling Mild to moderate kidney disease- regular

assessment of kidney function Women with severe kidney disease adviced against

contraception Therapeutic abortion justified in early pregnancy Anti-hypertensive drugs given for hypertension Fetal monitoring performed each visit Management of labour is like pre-eclampsia with the

aim of vaginal delivery

RENAL DISEASE AND HYPERENSION

DEFINITION-blood pressure of more than140/90mmhg or greater or an increase of 30 mm hg sysolic or 15 mm hg diastolic over the baseline value on atleast two occations

TYPES OF HYPERTENSIVE DISEASE IN PREGNANCY

1-Gestational hypertension/pregnancy induced hypertension

2-pre eclampsia 3-Eclampsia 4-preclampsia superimposed on chronic

hypertension 5-chronic hypetension

** INCIDENCE: 5-10% 0f all pregnancies . 20% recurrence

This is the third most important cause of maternal mortality worldwide

** DEFINITION OF HYPERTENSION:

D.B.P. > 90 mmHg or

S.B.P. > 140 mmHg along with

** PROTIENUREA: Proteinurea is defined as urinary excretion

0.3 g protein or greater in a 24-hour 30 mg/dl (+1 or greater on urine dip specimen)

** OEDEMA: 90% pregnancy. progressive

+/-

INCIDENCE & RISK FACTORSPre eclampsia occurs in 6-8% of all

live birth

RISK FACTORS Extremes of reproductive age

15 < & >35 Y Nulliparity Black race Hx of PET in a 1st degree

female relative Hx of PET in prior pregnancy DM Chronic renal disease Ch HPT

Multiple pregnancy twins 13 vs 6%

Hydatidiform mole Nonimmune hydrops fetalis Obesity 4.3% BMI < 19.8

kg/m²

13.3% BMI ≥ 35 kg/m²

Smoking ↓ risk of HPT

•Abnormal trophoblast invasion…

first 12 weeks, the decidual segments of the spiral arteries are invaded… elastic and muscular wall replaced by fibinoid walls

… by 20 weeks trophoblast invades intramyometrial segment of spiral arteries(high resistance low flow-low resistanc high flow) increase in utero placental flow

In pre eclampsia- trophoblast invasion is patchy & spiral arteries retain their muscular walls….

PATHOGENESIS Endothelial cell injury ↓ ↓ prostacyclin & ↑ thromboxaneA2 Vasospasm and endothelial cell dysfunction>>> platelet

activation and micro aggregate formation Rejection phenomenon (inadequate matenal Ab response)

Compromised placental perfusion Altered vascular reactivity ↑sensitivity to vasopressin EPN,

NEPN & angiotensin ↓ GFR with retention of salt & water ↓ intravascular volume ↑ CNS irritability DIC Uterine muscle stretch & ischemia Dietary factors Genetic factors

PATHOGENESISSummary of current hypothesis:

Immunological disturbance abnormal placental

implantation ↓ placental perfusion production of

substances that activate or injure endothelial cells of the

blood vessels multiple organ system involvement

SYMPTOMS & SIGNS ↑ BP Proteinuria Edema of the face & hands ( but it has been

dropped of the definition due to poor predictive value)

Headache Visual disturbance Epigastric pain Exaggerated reflexes

CLASSIFICATION OF PE ECLAMPSIASEVERE PRE ECLAMPSIA-Systolic BP >160 mmHg or

diastolic >110 mmHg on two occasions at least 6 hrs apart Proteinuria ≥ 5 g/24 hrs Oliguria < 500 cc /24 hrs Cerebral or visual symptoms Epigastric or Rt upper quadrant pain

Pulmonary edema or cyanosis Low PLt IUGR MILD PRE ECLAMPSIA any pre eclampsia that is not

considered severe

•Why screening

•Accuracy. Uterine artery doppler at 24 weeks, notching on both uterine arteries identifies 80% who will develop pre clampsia,,, 5% false positive

Management of pre eclampsia

OBJECTIVES Birth of an infant who subsequently thrives Complete restoration of health to the mother terminaton of pregnancy with the least possible trauma to

the mother & fetus

1- Hospitalization Women with new onset BP ≥ 140/90 Worsening BP Development of proteinuria in addition to existing BP

INITIAL HOSPITAL MANAGEMENT

Observe for headache , visual disturbance, epigastric pain & rapid wt gain

Wt daily Analysis for proteinuria every 2 days / daily BP in sitting position every 4 hrs except during sleep Blood investigations Hct, Plt, S creatinine, liver

enzymes Frequent evaluation of fetal size & AF Reduced physical activity but not absolute bed rest N diet & fluid intake

FURTHER MANAGEMENT Depends on: Severity of pre eclampsia Duration of gestation Condition of the Cervix Complete resolution of the signs & symptoms does not

occur till after deliveryLines of management Termination of pregnancy Antihypertensive therapy Anticonvulsant therapy Home health care if BP improved within few days Pt

can be managed as outpatient Home BP & urine protein monitoring . Instruction to come to hospital if she has waning symptoms . Rest at home

Termination of pregnancyIndications Term pregnancy with mild or severe Pre eclampsia Severe Pre eclampsia regardless of the gestational age Warning signs headache , visual disturbance, epigastric pain,

oliguria Eclampsia Pt must be stabilized & delivered immediatelyPreterm with mild Pre eclampsia Assess fetal wellbeing by NST,

BPP, DopplerMethods of termination IOL with prostaglandines to ripen the Cx followed by IV oxytocin Elective CS Severe Pre eclampsia with unfavorable

cervix

Antihypertensive therapy for severe pre eclampsia

Hydralazine

IV infusion or IV 5-10 mg bolus at 15-20 min interval

when diastolic BP ≥100-110 mm Hg or systolic BP ≥ 160 mmHg

Nifedipine 10 mg po repeated in 30 min Labetalol 10 mg IV / 20 mg after 10 min/ 40mg after

10min/80 mg (not to exceed 220 mg) Nitroprusside used only in PT not responding to other

drugs Diuretics not recommended because intravascular

volume depletion already exists in Pre eclampsia

Antihypertensive therapy

Mild pre eclampsia-There is no benefit of antihypertensive therapy

Reduction in the maternal BP with labetalol or nifedipine IUGR

ACI contraindicated IUGR, boney malformations, limb contracture, PDA, pulmonary hypoplasia, RDS, hypotension &death

Severe pre eclampsia-

Antihypertensive therapy is used to control BP untill the Pt delivers or in preterm for 48 48 hrs to allow time for glucocorticoid administration for fetal lung maturity then delivery

Fluid therapy Hyperosmotic agents not recommended

because intravascular influx of fluid subsequent escape of fluid to vital organs pulmonary edema & cerebral edema

LR 60-120 ml/hr Excessive fluid administration pulmonary edema & cerebral edema

Definitions

Chronic hypertension: A sustained BP > 140/90 that can antecedes

pregnancy or persists postpartum (beyond 6 weeks). HTN that is present before the 20th week of pregnancy may also be included as CHTN.

Chronic Hypertension

Often seen in patients who have other medical complications: obesity, diabetes, hyperlipidemia, cigarette smoking. Essential HTN – majority will have normal

pregnancies. Secondary HTN – parenchymal renal disease,

pheochromocytoma, Cushing’s syndrome, hyperthyroidism, etc.

Chronic Hypertension

If end-organ disease is present (renal, cardiac, cerebrovascular), there is an increased risk of morbidity and mortality. Maternal – superimposed preeclampsia, placental

abruption, congestive heart failure Fetal – intrauterine growth restriction, prematurity

and fetal death

Preconception Care of CHTN

Review the medical history: diagnosis and duration of hypertension, ongoing pharmacological treatment, known existence of organ damage or other compounding illnesses.

Review obstetrical history.

Preconception Care of CHTN

Physical exam and laboratory evaluation Urine analysis, urine culture/sensitivity, 24 hour urine

for total protein and creatinine clearance CBC Diabetes screening If the patient has severe hypertension, significant

proteinuria or prior poor obstetric outcome more extensive tests may be offered.

Preconception Care of CHTN

Optimize control with recommended medications. Methyldopa (Aldomet): extensively studied in

pregnant women, treatment of choice if needed. Central adrenergic inhibitor

Hydralazine: potent vasodilator, which acts directly on vascular smooth muscle.

Calcium channel blockers (Nifedipine): inhibits transmembrane calcium ion influx which causes vasodilation.

Antihypertensives

B-Adrenoreceptor blockers (e.g. atenolol, propranolol): possible fetal IUGR, neonatal respiratory depression, bradycardia and hypoglycemia

Angiotensin-converting enzyme inhibitors: not recommended for use in pregnancy

Thiazides diuretics: not recommended for use in pregnancy.

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