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

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