IN THE NAME OF GOD 1 Pregnancy in women with underlying renal disease - PowerPoint Presentation

1. IN THE NAME OF GOD1

2. Pregnancy in women with underlying renal disease2

3. What is the effect of pregnancy on the kidney disease?What is the effect of the kidney disease on pregnancy?3

4. EFFECT OF PREGNANCY ON KIDNEY DISEASEChanges in clinical manifestations Possible alterations in the long-term course of the disease4

5. …EFFECT OF PREGNANCY ON KIDNEY DISEASEThe degree of proteinuria increases in about one-half of cases Hypertension develops or worsens in about one-quarter of cases Marked worsening of edema also can be seen in women with the nephrotic syndrome. These changes generally resolve after delivery5

6. Effect on renal functioncreatinine <1.5 mg/dL Permanent decline in renal function in between 0 and 10 percent of women when the glomerular filtration rate is initially normal or only mildly reduced Other patients may experience a transient decline in renal function during pregnancy6

7. …Effect on renal functionplasma creatinine = 1.5 and 2.9 mg/dL plasma creatinine concentration tends to decline modestly during the first half of pregnancy (as it does in women without kidney disease, who have as much as a 50 percent increase in glomerular filtration rate) and then may rise above the previous baseline as the pregnancy progresses.7

8. …Effect on renal functionPlasma creatinine concentration > 3 mg/dL amenorrhea or anovulatory menstrual cycles. Thus, the likelihood of conception and then carrying the fetus to term is low; however, contraception is advisable because of poor pregnancy outcomes with advanced CKD8

9. Progression of kidney disease↑plasma creatinine concentration (above 1.5 mg/dL)Hypertension Type of disease also may be important as accelerated progression may be more likely in membranoproliferative glomerulonephritis, focal segmental glomerulosclerosis, and reflux nephropathy Women with vesicoureteral reflux may be at increased risk for urinary tract infection.9

10. EFFECT OF KIDNEY DISEASE ON PREGNANCYPregnancy in mild to moderate CKDThe rate of live births is above 90 %in women with normal renal function and slightly lower with modest CKD as long as the blood pressure is well controlled.10

11. …EFFECT OF KIDNEY DISEASE ON PREGNANCYFetal survival is lower with uncontrolled hypertensionThe risk of prematurity is increased among patients with a baseline plasma creatinine concentration above 1.4 mg/dLWomen with kidney disease are at significantly increased risk for preeclampsia. Although this syndrome generally occurs in the third trimester, women with underlying renal disease are at greater risk for second trimester preeclampsia.11

12. The diagnosis of pregnancy may be difficult in women with end-stage renal disease, particularly because serum levels of beta-hCG may be increased in the absence of pregnancy Among women suspected of being pregnant ultrasonography should be performed to verify the presence of a viable fetus and to obtain the approximate gestational age.12

13. Drug therapy Angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, and some immunosuppressive drugs (particularly cyclophosphamide) should be discontinued at the earliest indication of pregnancy.women who are not pregnant but are of child-bearing age should be warned about the potential consequences of these agents. 13

14. OBSTETRICAL MANAGEMENT OF WOMEN WITH UNDERLYING RENAL DISEASEIncreased frequency of prenatal visits; these should occur every two weeks until the third trimester and then weekly.Early detection and treatment of asymptomatic bacteriuria.Serial monitoring (at least monthly) of maternal renal function.14

15. …OBSTETRICAL MANAGEMENT OF WOMEN WITH UNDERLYING RENAL DISEASEClose monitoring for the development of preeclampsia.Fetal surveillance with ultrasound and fetal heart rate monitoring to assess fetal growth and well-being.15

16. …OBSTETRICAL MANAGEMENT OF WOMEN WITH UNDERLYING RENAL DISEASEAggressive treatment of maternal hypertension. Preterm intervention may be necessary in the presence of deteriorating renal function, severe preeclampsia, fetal growth restriction, or nonreassuring fetal testing (eg, fetal distress). In most women, elective delivery is indicated if labor has not occurred by the estimated date of confinement.16

17. Nephrolithiasis during pregnancy17

18. Affected patients usually present in the second or third trimester (approximately 20 percent in the first trimester).Most stones appear to be predominantly composed of calcium phosphate. 18

19. Risk factorsmild increase in urine calcium excretion lesser increases in urine citrate and magnesium excretion a rise in urine pH not rise urine volume urinary stasis, secondary to increased progesterone levels and diminished fluid intake, as a result of decreasing bladder capacity from the gravid uterus. 19

20. DIAGNOSIS renal/pelvic ultrasoundtransvaginal ultrasonography trial of symptomatic therapy 20

21. Preeclampsia/eclampsia  21

22. Preeclampsia: new onset of hypertension and proteinuria after 20 weeks of gestation in a previously normotensive woman :mild or severe Eclampsia : development of grand mal seizures in a woman with gestational hypertension or preeclampsia. The seizures should not be attributable to another cause. 22

23. severe preeclampsia Symptoms of central nervous system dysfunction Symptoms of liver capsule distention Hepatocellular injury Severe blood pressure elevation Thrombocytopenia Proteinuria:5 or more grams in 24 hoursOliguria <500 mL in 24 hoursSevere fetal growth restrictionPulmonary edema or cyanosisCerebrovascular accident 23

24. Gestational hypertensionHypertension without proteinuria (or other signs of preeclampsia) developing in the latter part of pregnancy It should resolve by 12 weeks postpartum. Women who first present with gestational hypertension are at greater risk for developing preeclampsia as the pregnancy progresses .This is most likely when gestational hypertension develops before 30 weeks of gestation. 24

25. Evaluation of proteinuria in pregnancy25

26. In non-pregnant individuals, abnormal total protein excretion is typically defined as greater than 150 mg daily. In normal pregnancy, urinary protein excretion increases substantially, due to a combination of increased glomerular filtration rate and increased permeability of the glomerular basement membrane .Hence, total protein excretion is considered abnormal in pregnant women when it exceeds 300 mg/24 hours.26

27.  Routine antepartum care includes dipstick protein testing of a random voided urine sample at each prenatal visit. The purpose is detection of preeclampsia.27

28. Results range from negative to 4+, corresponding to the following estimates of protein excretion:NegativeTrace - between 15 and 30 mg/dL1+ - between 30 and 100 mg/dL2+ - between 100 and 300 mg/dL3+ - between 300 and 1000 mg/dL4+ - >1000 mg/dLA positive reaction (+1) for protein develops at the threshold concentration of 30 mg/dL, which roughly corresponds to a 24-hour urinary protein excretion of 300 mg/day, depending on urine volume.28

29. Urine protein to creatinine ratio urine PC ratio above 0.7 g protein/g creatinine strongly predicts significant proteinuria while a urine PC ratio less than 0.15 mg/g can be considered normal (predictive of less than 300 mg protein in a 24-hour collection), so confirmatory testing with 24-hour urine collection probably isn't necessary in these individuals. 29

30. Women with urine PC ratio results between 0.15 and 0.7 mg/mg should have a 24-hour urine collection to accurately quantify proteinuria. If a 24 hour urine collection is not obtained, guidelines define proteinuria as random urine sample PC ratio ≥0.26 mg/g.30

31. DIFFERENTIAL DIAGNOSIS OF PROTEINURIARenal disease versus preeclampsiaSuperimposed preeclampsia Nephrotic syndrome 31

32. Prescribing Drugs in Kidney Disease32

33. Initial Patient Assessment for Drug DosingClinical evaluation always begins with a careful history,including previous medication, drug-related allergy or toxicity,and concurrent medicines. Reviewing the possibility of drug interactions Efforts should therefore be made to limit the number of drugs prescribed to take advantage of the fact that one drug can be used to treat several conditions.33

34. …Initial Patient Assessment for Drug DosingPhysical examination is necessary to assess ECF volume and determine the distribution volume of drugs. Edema and ascites increase the distribution volume of many drugs. Evaluating functional impairment of other excretory organs is also important because the failure of other organs limits the possibilities for alternate pathways of drug and metabolite elimination.34

35. Calculating Drug DosesThe goal of the initial drug dose is to achieve therapeutic drug concentrations rapidly. A loading dose equivalent to the dose given to a patient with normal kidney function should be given to patients with impaired kidney function if the drug’s half-life is particularly long and if the physical examination suggests normal ECF volume. 35

36. The fraction of the normal dose recommended for a patient with kidney failure can be calculated as follows: Df = t½ Normal/t½ Kidney failure36

37. Dose in impaired kidney function = Normal dose × DfDose interval in impaired kidney function = Normal dose × Interval / Df37

38. A combined approach using the dose-reduction and interval prolongation methods is often practical. 38

39. Impact of Acute Kidney Injury AKI is able to alter both the pharmacokinetics and pharmacodynamics of drugs. Glomerular filtration and tubular secretion may be altered, with direct effects on drug handling. Altered intestinal permeability and body composition during acute illnessNonrenal drug clearance by other organs may be affected by AKI. Accumulation of active metabolites, like the parent compound, is also often affected in AKI. 39

40. Drug Removal by Dialysis Factors Affecting ClearanceDiffusion of the drug across the dialysis membrane. Treatment time Blood as well as dialysate flow rates.Membrane 40

41. Drug Dosing in Peritoneal DialysisPD is much less efficient for removing drugs than HD. PD is most effective for lower-molecular-weight drugs that are not extensively bound to serum proteinsDrugs that have small volumes of distribution are more effectively removed than those that are distributed in adipose tissue or have extensive tissue binding. The number and volume of PD exchanges done daily. In concert with the fact that PD does not rapidly remove most drugs, many drugs are well absorbed when placed in peritoneal dialysate .41

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44. THANK YOU44