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32 Cards in this Set

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Renal changes in preg
hypertrophy, more smooth muscle motility (pelvis/ureter dilation, less bladder emptying, reflex from bladder to ureters which is backwards)

pH changes so more risk of infection
Vasc changes in preg
Endothelial relaxation

Small vessels dilate

large vessels have more compliance

these changes are early in the pregnancy
Physiological changes in preg
less resistance to vasculature

more CO, less BP, more blood volume (anemic though)

renal blood flow and thus GFR increases.
after preg to assess renal func
must wait 3 months till they get back to their baseline.
What happens to the following in preg
BUN, creat, sodium pH, bicarb, albumin, urine protein, RBC mass
BUN down, creat down - filtering more

sodium down

pH up and bicarb is down (so a respiratory alkalosis with compensation)

albumin low

urine prot increased (more GFR)

RBC mass increases. but remember, plasma volume increases more (Anemia)
failure to drop creatinine during pregnancy....
is an indication of underlying kidney disease.
Abnormal changes in preg in a pt who has chronic kidney disease and HTN
they oppose the normal.

less endothelial relaxation (periph vasoconstriction and HTN)

Less large vessel compliance.
Conclusions of studies of chronic kidney disease and pregnancy
it is possible, contrary to previous belief.

but more risk of an adverse outcome and the degree of risk is proportional to the degree of renal impairment.
GFR and stages of chronic kidney disease
need to know these...

1 - >90
2 - 60-89
3 - 30-59
4 - 15-29
5 - <15 - NEED DIALYSIS!!!!
6 - on dialysis
worse CKD pts are more likely to...
not increase their blood vol, not increase their GFR, not increase RBC mass, have MORE protein excretion
risks to fetus and mother
fetal risks are way way worse.

fetus - prematurity, intrauterine growth retardation, spont abortion, intrauterine death

maternal - HTN/pre-eclampsia, worsening kidney function, death (usually HTN or pre-exlampsia)
more likely to have preg complic with ___ ckd
higher stage.

duh

includes lower birth weight, preterm deliv and perinatal death.
how does preg affect course of chronic kidney disease?
hyperfiltration of preg may make CKD progress.

<10% chance of GFR decreasing. more likely to have an increase in BP
GFR pattern in pts with CKD
goes up until 2nd trim then back to normal in 3rd trim. similar to normal. but more pts have weird patterns.
the one disease that presents MORE COMMONLY in preg
lupus
pregnancy effects on normal kidneys
aside from lupus, not more likely to get any renal disease.

but because of new attention, may discover and pre-existing undx kidney disease (more proteinuria, failure to decrease creatinine of HTN would sugest this)
HTN and pregnancy with CKD
If HTN before, less reduction in BP during preg. Same goes if they had CKD before.

in fact, if CKD stage 4-5, BP will go UP during pregnancy!

HTN is a risk factor for poor preg outcomes in all stages of CKD!!!
Affects of HTN during preg
abnormal endothel cells, less placental perfusion, prematurity, intrauterine growth retardation.
categories of HTN in preg
Pre-existing - if mild, it improves if renal func is normal. if not mild or moderate to severe chronic kidney disease, it worsens.

Pregnancy-induced HTN - usually early in preg. this is a red flag for underlying renal disease.

Pre-eclampsia (no HTN after the preg) - systemic disorder and histo is related to thrombotic microangiopathies.
Pre-eclampsia
After 20th week. May be earlier if pt had chronic kidney disease or HTN.

Often hours to days before the delivery.
signs of pre-eclampsia
HTN, rapid weight gain/edema, proteinuria

sometimes acute renal failure, encephalopathy (HA, headache, sz), fetal distress due to placental dysfunction.
HELLP syndrome
a variant of pre-eclampsia that is a little more serious

Hemolysis, elev liver enzymes, low platelets.
Lab studies for pre-clampsia
proteinuria, low platelets, high serum uric acid (the last one isn't really good...)
Pathogen of pre-eclampsia
Endothel cell activ and proliferation so small vessels are occluded. Microthrombi in placenta, kidney, nervous system, liver.
VEGF and sFlt-1 findings in pre-eclampsia
Flt1 - tyrosine kindase receptor - soluble form released by placenta. It binds VEGF (also released by placenta)

So the soluble form binds VEGF.

Normally, surge in sFlt1 before labor. But in pre-eclamptic pts (5 weeks before), you often see excess sFlt-1 and decreased VEGF (endothel cell is dysfunctional and procoag and vasoconstricting)
risk factors for pre-eclampsia
first or wifely-spaced preg

maternal age

CKD

pre-existing HTN

obestity

multiple pregs
Mgmt of pre-eclampsia
admit with bed rest.

fluids (NO DIURETICS - WILL WORSEN TISSUE PERFUSION!!!)

IV magnesium

induce delivery
how to manage non-preeclamptic HTN in preg
target 120/80

seatch for underlying kidney disease after preg.

want more vascular volume in a preg pt so no diuretics and ACE/ARBs are teratogenic after 1st trim.

wanna use methyl dopa (can cause false positive coombs), nifedipine, labetolol or IV nitrates.
Preg in renal transplant recipients
the rejection risk is lower during preg and more risk for 3-6 months post-partum.
Preg in women on dialysis
it is possible but hard.

they are less fertile and have high risk for HTN, preeclamp, fetal loss, abrupption, prematurity, and IUGRestriction.
Summary
Chronic kidney disease modifies the physiological responses to pregnancy

Chronic kidney disease and hypertension are independent and interrelated risk factors for adverse fetal and maternal outcomes in pregnancy

The magnitude of risk varies with severity of CKD and HTN

The greatest risks are to the fetus

Pre-eclampsia is a systemic condition unique to pregnancy

Successful pregnancy is common in transplant patients and challenging in dialysis patients
General recs if someone with CKD wants to get preg
CKD stages1 and 2
The risks are greater than normal but the chances of a good outcome are 95% or better
Should be managed in consultation with Materno-fetal Medicine service or High Risk OB clinic

CKD stages 3 and 4
Significant incidence prematurity and preeclampsia
But good outcomes can be achieved with intensive prenatal management

CKD stage 5
High risk adverse outcome

And note - Hypertension worsens risks at all levels of CKD