Download - Pregnancy and kidney disease: case studies
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Pregnancy and kidney disease: case studies
Matt Hall
May 28th 2009
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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!
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What do you need to know?
Blood pressure and treatment
Serum creatinine Presence of UTI
ProteinuriaPast obstetric
history
Medication
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Management interventions
Treat bloodpressure
Aspirin
LMWH
Deliver baby
Treat infection
Dialysis
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Case 1
• Age 34. Primigravida.
• Renal transplant 2001 – ESRD ?cause
• Attended pre-conception counselling 4 months before conception
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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
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Case 1 – at booking
Didn’t realise she was pregnant until 22 weeks
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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
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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
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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
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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
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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
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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
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Outcome
Weight: 3.25kgApgar: 101 and 105
Status: Alive and well
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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
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Case 2
• 23 year old. Primigravida.
• Type 1 DM.
• Retinopathy.
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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
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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
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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
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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
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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
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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
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Outcome
Weight: 3.32kgApgar: 91 and 95
Status: Alive and well
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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
)
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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
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Case 3
• 29 year old. G2 P1+0
• IgA nephropathy diagnosed following first pregnancy
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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
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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.
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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
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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
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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
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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
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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
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Outcome
Weight: 1.75kgApgar: 91, 105
Status: Alive and well
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Outcome
0
50
100
150
200
250
300
350
Crea
tinin
e
Renal biopsy
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Summary
• Stats say that adverse maternal and fetal outcome depends on:– blood pressure– baseline creatinine
• Patients don’t often read the stats
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Summary
Treat bloodpressure
Aspirin
LMWH
Deliver baby
Treat infection
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http://renal.pinetreeavenue.com
• Soon to be changed to:
http://www.emidsrenaltraining.org.uk