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
Proteinuria
Presence of UTI
Past obstetric
history
Medication
Management interventions
Aspirin
Treat blood
pressure
Treat infection
Dialysis
Deliver baby
LMWH
Case 1
• Age 34. Primigravida.
• Renal transplant 2001 – ESRD ?cause
• Attended pre-conception counselling 4
months before conception
Case 1 - baseline
Blood pressure
and treatment
BP 100/60 on no Rx prior to conception
Serum creatinine
Creatinine 122μmol/l (eGFR 44ml/min), stable
Presence of UTI
No history of recurrent UTI
Proteinuria
PCR 23 mg/mmol creatinine
Past obstetric
history
Not applicable
Medication
Prednisolone, tacrolimus, azathioprine
Case 1 – at booking
Didn’t realise she was
pregnant until 22 weeks
Case 1 – 24 weeks
Blood pressure
and treatment
BP 162/102
Serum creatinine
Creatinine 90μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 66 mg/mmol creatinine
Past obstetric
history
Not applicable
Medication
Prednisolone, tacrolimus, azathioprine
Methyldopa
Case 1 – 28 weeks
Blood pressure
and treatment
BP 139/84
Serum creatinine
Creatinine 103 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 69 mg/mmol creatinine
Past obstetric
history
Not applicable
Medication
Prednisolone, tacrolimus, azathioprine, methyldopa
Case 1 – 32 weeks
Blood pressure
and treatment
BP 141/83
Serum creatinine
Creatinine 95 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 115 mg/mmol creatinine
Past obstetric
history
Not applicable
Medication
Prednisolone, tacrolimus, azathioprine, methyldopa
Case 1 – 35 weeks
Blood pressure
and treatment
BP 118/82
Serum creatinine
Creatinine 112 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 138 mg/mmol creatinine
Past obstetric
history
Not applicable
Medication
Prednisolone, tacrolimus, azathioprine, methyldopa
Case 1 – 37 weeks
Blood pressure
and treatment
BP 139/84
Serum creatinine
Creatinine 121 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 69 mg/mmol creatinine
Past obstetric
history
Not applicable
Medication
Prednisolone, tacrolimus, azathioprine, methyldopa
Case 1 – 39 weeks
Blood pressure
and treatment
BP 149/95
Serum creatinine
Creatinine 141 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 111 mg/mmol creatinine
Past obstetric
history
Not applicable
Medication
Prednisolone, tacrolimus, azathioprine, methyldopa
Induction
Outcome
Weight: 3.25kg
Apgar: 101 and 105
Status: Alive and well
16
/1
16
/0
16
/1
16
/0
16
/1
16
/0
16
/1
16
/0
16
/1
16
/0
16
/1
16
/0
16
/1
2/
0
6/
0
2/
0
6/
0
2/
0
6/
0
2/
0
6/
0
2/
0
6/
0
2/
0
6/
0
2/
0
8
8
7
7
6
6
5
5
4
4
3
3
2
eGFR (ml/min)
Outcome
70
Acute rejection
60
50
40
30
20
10
0
Case 2
• 23 year old. Primigravida.
• Type 1 DM.
• Retinopathy.
Case 2 – baseline
Blood pressure
and treatment
BP ?: no Rx
Serum creatinine
Creatinine 84μmol/l (eGFR 78 ml/min)
Presence of UTI
No history of recurrent UTI
Proteinuria
Not recorded – no known h/o proteinuria
Past obstetric
history
Not applicable
Medication
Insulin, lamotrigine
Aspirin
Case 2 – 20 weeks
Blood pressure
and treatment
BP 107/62: no Rx
Serum creatinine
Creatinine 85μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 331 mg/mmol creatinine
Past obstetric
history
Not applicable
Medication
Insulin, lamotrigine, aspirin
LMWH
Case 2 – 22 weeks
Blood pressure
and treatment
BP 121/69: no Rx
Serum creatinine
Creatinine 85μmol/l
Presence of UTI
No UTI
Proteinuria
4.14g/24h. Albumin 32g/dl. Oedema.
Past obstetric
history
Not applicable
Medication
Insulin, lamotrigine, aspirin, LMWH
Case 2 – 28 weeks
Blood pressure
and treatment
BP 126/82: no Rx
Serum creatinine
Creatinine 71 μmol/l
Presence of UTI
No UTI
Proteinuria
5.53g/24h. Albumin 33g/dl.
Past obstetric
history
Not applicable
Medication
Insulin, lamotrigine, aspirin, LMWH
Case 2 – 34 weeks
Blood pressure
and treatment
BP 104/65: no Rx
Serum creatinine
Creatinine 77 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 683 mg/mmol. Albumin 32g/dl.
Past obstetric
history
Not applicable
Medication
Insulin, lamotrigine, aspirin, LMWH
Case 2 – 37 weeks
Blood pressure
and treatment
BP 119/71: no Rx
Serum creatinine
Creatinine 81 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 622 mg/mmol. Albumin 34g/dl.
Past obstetric
history
Not applicable
Medication
Insulin, lamotrigine, aspirin, LMWH
Induction at
38 weeks
Outcome
Weight: 3.32kg
Apgar: 91 and 95
Status: Alive and well
05/01/2009
05/12/2008
05/11/2008
05/10/2008
05/09/2008
05/08/2008
05/07/2008
05/06/2008
05/05/2008
05/04/2008
05/03/2008
05/02/2008
05/01/2008
05/12/2007
PCR (mg/mmol creatinine)
Outcome
800
700
600
500
400
300
200
100
0
26/02/2009
26/01/2009
26/12/2008
26/11/2008
26/10/2008
26/09/2008
26/08/2008
26/07/2008
26/06/2008
26/05/2008
26/04/2008
26/03/2008
26/02/2008
26/01/2008
26/12/2007
26/11/2007
26/10/2007
26/09/2007
26/08/2007
26/07/2007
26/06/2007
26/05/2007
26/04/2007
26/03/2007
Creatinine
Outcome
120
100
80
60
40
20
0
Case 3
• 29 year old. G2 P1+0
• IgA nephropathy diagnosed following first
pregnancy
Case 3 - baseline
Blood pressure
and treatment
BP 105/70 prior to conception
Serum creatinine
Creatinine 91μmol/l (eGFR 66ml/min)
Presence of UTI
No history of recurrent UTI
Proteinuria
PCR 175 mg/mmol creatinine
Past obstetric
history
Nephrotic from 20 weeks.
Pre-eclampsia at 35 weeks.
Medication
Ramipril
Case 3 – 10 weeks
Blood pressure
and treatment
BP 144/90
Serum creatinine
Creatinine 85μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 393 mg/mmol creatinine but 1.9g/d.
Albumin 29 g/dl
Past obstetric
history
Nephrotic from 20 weeks.
Pre-eclampsia at 35 weeks.
Medication
Case 3 – 12 weeks
Blood pressure
and treatment
BP 150/99 but good 24h BPM
Serum creatinine
Creatinine 85μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 353 mg/mmol creatinine.
Albumin 28 g/dl
Past obstetric
history
Nephrotic from 20 weeks.
Pre-eclampsia at 35 weeks.
Medication
LMWH
Case 3 – 22 weeks
Blood pressure
and treatment
BP 132/85
Serum creatinine
Creatinine 103μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 241 mg/mmol.
Albumin 27 g/dl
Past obstetric
history
Nephrotic from 20 weeks.
Pre-eclampsia at 35 weeks.
Medication
LMWH
Case 3 – 27 weeks
Blood pressure
and treatment
BP 138/87
Serum creatinine
Creatinine 123 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 444 mg/mmol.
Albumin 23 g/dl
Past obstetric
history
Nephrotic from 20 weeks.
Pre-eclampsia at 35 weeks.
Medication
LMWH
Case 3 – 32 weeks
Blood pressure
and treatment
BP 127/76
Serum creatinine
Creatinine 107 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 680 mg/mmol.
Albumin 22 g/dl
Past obstetric
history
Nephrotic from 20 weeks.
Pre-eclampsia at 35 weeks.
Medication
LMWH
Evidence of poor fetal growth
3x/wk
Admit
visits
Case 3 – 34 weeks
Blood pressure
and treatment
BP 131/71
Serum creatinine
Creatinine 125 μmol/l
Presence of UTI
No UTI
Proteinuria
PCR 708 mg/mmol.
Albumin 25 g/dl
Past obstetric
history
Nephrotic from 20 weeks.
Pre-eclampsia at 35 weeks.
Medication
LMWH
Elective CS
at 35+5/40
Outcome
Weight: 1.75kg
Apgar: 91, 105
Status: Alive and well
-0
Oc 3
t -0
Ja 3
n0
Ap 4
r -0
4
Ju
l-0
Oc 4
t -0
4
Ja
n0
Ap 5
r-0
5
Ju
l-0
Oc 5
t -0
5
Ja
n0
Ap 6
r -0
6
Ju
l-0
Oc 6
t -0
Ja 6
n0
Ap 7
r -0
7
Ju
l-0
Oc 7
t -0
Ja 7
n0
Ap 8
r -0
8
Ju
l-0
Oc 8
t -0
Ja 8
n09
Ju
l
Creatinine
Outcome
350
300
250
200
150
Renal biopsy
100
50
0
Summary
• Stats say that adverse maternal and fetal
outcome depends on:
– blood pressure
– baseline creatinine
• Patients don’t often read the stats
Summary
Aspirin
Treat blood
pressure
Treat infection
Deliver baby
LMWH
http://renal.pinetreeavenue.com
• Soon to be changed to:
http://www.emidsrenaltraining.org.uk