nephrology

1. Renal Disorders in Pregnancy
AJKD 2018
PRESENTER –DR SCIENTHIA SANJEEVANI
MODERATOR DR SAHIL BAGAI

2. Physiologic Changes in Pregnancy
 BP decrease in systemic blood pressure (BP), usually reaching a nadir by 20 weeks’
gestation.
 Glomerular filtration rate (GFR) increases by >50%, resulting in a physiologic
reduction in serum creatinine (Scr) level in the setting of hyperfiltration. Normal
Scr level in pregnancy is in the 0.4- to 0.6-mg/Dl range.
 Physiological hydronephrosis The combination of smooth muscle relaxation due
to progesterone and mechanical compression by the enlarging uterus can cause
physiologic hydronephrosis and retention of urine in the collecting system
during pregnancy

3. PROTEINURIA
 Urine PCR increases during the course of normal pregnancy, from 60 to 90 mg/d to
180 to 250 mg/d, as measured by a 24-hour urine collection.
 Threshold for elevated proteinuria in pregnancy has been set at a higher level of
protein excretion of 300 mg/d
 Increase in tubular proteinuria, reflected as an increase in urinary retinol binding
protein, as opposed to an increase in albuminuria (glomerular source).
 UPCR > 0.3 g/g in favor in the diagnosis of preeclampsia
 Isolated proteinuria- increased UPCR in the absence of hypertension or kidney
present in 15% of pregnancies.

4. IMMUNITIY
 shift from TH1 to TH2 --important for tolerance to fetal antigens, trophoblast
invasion, and placental formation.
 Regulatory T cells, which promote immune tolerance, is increased in normal
pregnancy, further contributing to establishing fetal tolerance.
 In autoimmune diseases, such as SLE lead to increased risk for pregnancy
complications, such as preeclampsia, and poor fetal and maternal outcomes.

5. Physiologic Changes in Pregnancy
Increased
 Blood volume
 Cardiac output
 Levels of nitric oxide and relaxin
 Relative resistance to vasoconstrictors
 GFR by 50%
 Urine protein excretion
 TH2 phenotype
 Circulation of Tregs
Decreased
 Systemic vascular resistance
 Systemic blood pressure
 Serum creatinine

6. Hypertension in Pregnancy
 6% to 8% of pregnancies
 chronic hypertension, gestational hypertension, preeclampsia, eclampsia.
 Chronic hypertension Patients who have a known history of hypertension before
pregnancy or those who are found to have BPs ≥ 140/90 mm Hg before 20 weeks
of gestation. They have an increased risk for superimposed preeclampsia, which
can occur in up to 35% of their pregnancies
 Gestational hypertension occurs during the second half of pregnancy in patients
with no history of pre-existing hypertension, and has an incidence of 6% to 7%.

7. Preeclampsia
Diagnostic Criteria
SBP ≥ 140 mm Hg or DBP ≥ 90 mm Hg (aMeasured on 2 occasions, at least 4 hours apart, after 20
weeks of pregnancy in a previously normotensive patient) AND
 Proteinuria ≥ 300 mg/d, or UPCR ≥ 0.3 g/g OR
 If no proteinuria is present, new onset of any of the followingb:
 Platelets < 100 ×103/Μl
 Scr > 1.1 mg/dL or doubling of Scr concentration in the absence of other kidney disease
 Liver transaminases 2× upper limits of normal
 Pulmonary edema
 Cerebral or visual symptoms (new-onset and persistent headaches, blurred vision, flashing lights)

8. PATHOGENESIS
 imbalance between proangiogenic VEGF and PIGF and antiangiogenic (soluble fms-like tyrosine kinase 1
[sFlt-1] and soluble endoglin , favoring the latter.
 Angiogenic abnormalities -severe and early (<34 weeks of gestation) forms of preeclampsia, but not for
disease (≥34 weeks of gestation).
 sFlt-1:PIGF ratio- screening tests to predict preeclampsia, currently not recommended for clinical practice.
 The only available screening approach -serial BP measurements during pregnancy.
AT RISK PATIENTS
 patients with history of preeclampsia and preterm delivery at less than 34 weeks
 those with history of preeclampsia in 2 or more pregnancies
TO PREVENT PREECLAMPSIA
low-dose aspirin during the late first trimester in patients with moderate or high risk for preeclampsia,

9. MANAGEMENT
 Delivery remains the mainstay of therapy

10. Hypertension Management
Control of Hypertension in Pregnancy [CHIP] Trial
 analyzed 987 pregnant women with pre-existing or gestational hypertension who
were randomly assigned to less tight BP control (target diastolic BP, 100 mm
Hg) versus tight BP control (targetdiastolic BP, 85 mm Hg) during pregnancy.
 No significant differences were found other than a higher frequency of severe
maternal hypertension in the less tight control arm (40.6% vs 27.5%, respectively)

11. American College of Obstetricians and Gynecologists recommends
 gestational hypertension or preeclampsia with persistent BP ≥ 160/110 mm Hg.
 Delivery is recommended for these women at 37 weeks or later if no severe
features of preeclampsia are observed.
 women with pre-existing hypertension if systolic BP is ≥160 mm Hg and/or
diastolic BP is ≥105 mm Hg, without evidence of end-organ damage.
The National Institute for Health and Care Excellence (NICE) recommends
 initiation of treatment in pregnant women with systolic BPs ≥ 150 mm Hg
diastolic BPs ≥ 100 mm Hg

12. AKI
CAUSES
PRERENAL AKI
 Hemorrhage
 pulmonary embolism
 Heart failure
 Sepsis
 Hyperemesis gravidarum leading to hypovolemia
RENAL
Acute tubular necrosis
 acute fatty liver of pregnancy
 amniotic fluid embolism
 severe preeclampsia
 HELLP
 hypertensive disorders of pregnancy
Acute cortical necrosis
 Severe hypotension
 Hypercoaugulable state

13. Kidney biopsy
 Kidney biopsy should be considered in women at less than 32 weeks of gestation,
when delivery is not a viable alternative and treatment may result in prolongation of a
desired pregnancy
 Most common reason for biopsy- to differentiate between pre eclampsia and
glomerulonephritis
 COMPLICATION
significantly higher later in pregnancy -peak at 25 weeks of gestation
 major bleeding requiring transfusion
 embolization
 severe obstetric complications- early preterm delivery, rarely fetal death

14. Renal cortical necrosis
Coagulative necrosis of glomeruli and tubules surrounded by dense neutrophilic infiltrate
Thrombus occluding the vascular lumen

15. HELPP syndrome
 hemoglobin-containing casts in renal tubules
 acute tubular necrosis

16. Lupus nephritis
 Patients with SLE should have quiescent disease for at least 6 months before attempting to
conceive.
 Extrarenal lupus flares are more common during the second and third trimesters, whereas kidney
disease activity seems to be more common during the postpartum period.
 Evidence suggests that severe maternal flares occur in 3% to 5% of pregnancies
 Renal flare not an absolute contraindication to maintaining a pregnancy.
 Immunologic activity at conception (as measured by low C3 levels and anti-DNA antibodies)-best
predictor of renal flares.
 Low C4 levels and high anti-C1q antibody levels -associated with early flares (encountered during
the first or second trimesters of pregnancy).
 High body mass index associated with increased risk for late flares, defined as flares encountered
during the third trimester or postpartum period

17. PROGNOSIS
PROMISSE STUDY
 Predictors of Pregnancy Outcome: Biomarkers in Antiphospholipid Antibody Syndrome and Systemic
Lupus Erythematosus
 385 pregnant patients with SLE
 evaluated adverse pregnancy outcomes and pregnancy-related flare rates.
ADVERSE PEGNANCY OUTCOME 19%
FETAL DEATH 4%
NEONATAL DEATH 1%
PRETERM DELIVERY 9%
SMALL FOR GESTATIONAL AGE 10%

18. Independent predictors of adverse pregnancy outcomes included
 presence of a lupus anticoagulant
 physician global assessment of disease activity score > 1
 antihypertensive use
 Platelet count < 100 × 103/μL.

19. Predictor of fetal outcomes
MISCARRIAGES Amount of steroid taken in year before conception
stillbirth No of SLE flares 1 yr before conception
Pre term births APLA and anti dsDNA levels
Complete congenital heart block • 1-2 % after exposure to to SSA/Ro and/or SSB/ La
antibodies.
• Incidence increases to 20% if there is a maternal history
of previous delivery of an infant with neonatal lupus.

20. Antiphospholipid antibody syndrome
 Antiphospholipid antibodies may be present in up to 25% of SLE pregnancies
 screening is recommended
 mainstay of APS management – anticoagulation using either unfractionated heparin or
lowmolecular- weight heparin during pregnancy.
 INDICATION
-all patients with SLE who have antiphospholipid antibodies and a history of thrombotic
event(s)
-for those lacking a history of thrombotic event(s), but who meet obstetric criteria for APS,
such as 3 or more pregnancy losses, or a late pregnancy loss.

21. MANAGEMENT OF LUPUS

22. ATYPICAL HUS
 microangiopathic hemolytic anemia, thrombocytopenia, and decreased kidney function as a result of
uncontrolled alternate pathway complement activation.
 Presents most commonly in post partum period
 D/D
 TTP- most commonly in the third trimester
 Severe pre-eclampsia with HELPP
 TREATMENT
 When suspected, plasma exchange should be started while awaiting ADAMTS13 (von Willebrand
factor protease) activity results (<10% is associated with TTP). I
 If ADAMTS13 activity is normal and aHUS is suspected,eculizumab
 PROGNOSIS - before the use of eculizumab was poor and associated with high morbidity and
mortality rates.

23.  mutations in the genes encoding for complement regulatory proteins may
enhance the risk for preeclampsia in other disease entities, such as SLE and/or
antiphospholipid antibodies
 overlap in disease processes leads to difficulty in diagnosis

24. Immunoglobulin A Nephropathy
 pregnancy does not affect long term kidney function
 Systemic review and meta analysis (Liu Y et al) –
 high risk for pregnancy complications, including pregnancy loss, preterm delivery,
low birth weight, preeclampsia/ eclampsia
 women with hypertension, baseline estimated GFR < 60 mL/min/1.73 m2, or
proteinuria with protein excretion > 1 g/d had significantly higher risk for kidney
disease progression

25. MANAGEMENT
 Mild, stable, or slowly progressive IgA nephropathy do not receive immunosuppressive
treatment.
 In most cases, ACE inhibitor treatment should be discontinued before pregnancy and
immunosuppressive agents should be reviewed and switched to pregnancy-safe
ideally before conception or at the first sign of pregnancy o minimize risk to the fetus.
 Steroids can be used in pregnancy if immunosuppression is needed for more active disease.

26. DIABETIC NEPHROPATHY
 present in 6% of pregnant women with type 1 DM.
 Type 2 DM and associated nephropathy less common among women of child-bearing age.
 risk for pregnancy complications in young women with type 1 DM is related to the degree of pre
pregnancy decrease in kidney function
 Progression to ESRD highest in women with Scr levels > 1.4 mg/dL.
 In the absence of RAAS blockade and under the physiologic conditions of pregnancy, urinary albumin
excretion may increase substantially during the course of pregnancy in women with diabetic
nephropathy

27. MANAGEMENT
 Prepregnancy counseling is critical
 Tighter glycemic control for at least 6 months before conceiving associated with improved outcomes
 ADA recommends targeting HbA1c goal of <6.5% while watching carefully for hypoglycemia.
 Insulin is the mainstay of therapy
 OHA- metformin and glyburide may be continued in some women with pregestational type 2 DM and
glycemic control.
 A baseline ophthalmic examination before pregnancy is needed in all women with DM.
 Women with moderate to severe retinopathy at the time of conception may need more careful monitoring
even intervention in pregnancy.
 women with high HbA1c at the beginning of pregnancy who has rapid improvement in glycemic control in
pregnancy is associated with worsening of retinopathy
 ACE inhibitors /ARB contraindicated in pregnancy
 3 to 6 months of therapy before conceiving may have renal protective effects.
 ASPIRIN- as preeclampsia prophylaxis given the theoretical benefit and overall low risk for harm.

28. PROGNOSIS
 Women with type 1 DM are at increased risk for preeclampsia irrespective of the
baseline proteinuria
 miscarriage, congenital malformations, preterm delivery, macrosomia, and
perinatal mortality
 Patients with diabetic retinopathy may have worsening in the setting of
pregnancy.

29. Nephrotic Syndrome in Pregnancy
 If presentation is before 20 weeks’ gestation, kidney biopsy can be safely
performed to determine whether immunosuppression is needed.
 Close differential – preeclampsia, particularly after 20 weeks of gestation.
 women with a pre-existing diagnosis should be in clinical remission before
conceiving

30. FSGS
Primary FSGS
 diffuse foot-process effacement (>80%)
 acute or subacute onset of nephrotic syndrome
Secondary FSGS
 moderate foot-process effacement. Primary FSGS will present
 presents with non–nephrotic-range proteinuria and decreased kidney function.
 Glucocorticoids and/or calcineurin inhibitors can be safely used for primary FSGS
in pregnancy

31. MINIMAL CHANGE DISEASE
 Rare in pregnancy
 Management
 antihypertensive therapy and glucocorticoids.
 Diuretics to be used with caution – theoretical concern of causing intravascular
volume depletion leading to systemic vasoconstriction and placental
hypoperfusion
 Restricted fluid intake and low-salt diet
 Patients with relapsing disease desiring to become pregnant can be safely treated
with AZA or calcineurin inhibitors.

32. Membranous nephropathy
 in women of child-bearing age is rarely primary and most often secondary to other
causes
 Underlying diseases, such as SLE
 drug exposure (in particular, NSAIDS or biologic agents)
 Infection -hepatitis B or hepatitis C virus infection, syphilis
 Malignancy
MANAGEMENT
 ACE inhibitors, lipid-lowering therapy, warfarin, and cyclophosphamide are
contraindicated.
 Prednisone and calcineurin inhibitors can be used

33.  PROGNOSIS
 In the setting of massive proteinuria and hypoalbuminemia (albumin < 2
women may be at risk for thrombosis

34. CKD in Pregnancy
Adverse Perinatal Outcomes in Women With CKD

35. PROGNOSIS
 Classic study by Jones and Hayslett of 67 women (with 82 pregnancies) with Scr levels
≥ 1.4 mg/dL in pregnancy
 51% of women had no change in GFR
 31% had a decline in kidney function that persisted 6 months postpartum
 Women with antepartum Scr levels > 2.0 mg/dL were at particularly high risk for
kidney function
 Women with milder CKD (Scr < 1.4 mg/dL) may expect to have good maternal and
fetal outcomes,
 women with advanced disease (Scr, 1.4-2.9 mg/dL) are at high risk for pregnancy
complications.
 Women with Scr values ≥ 3.0 mg/ dL may permanently lose kidney function with
pregnancy.
 The underlying disease, such as DM or lupus nephritis, may impose additional
specific risks

36. ESRD in Pregnancy
 Fertility is significantly diminished in woman requiring dialysis therapy, may be
due to erratic and/or absent menstrual cycles
 Diagnosis of pregnancy is also delayed
 significant elevations of hCG with appropriate doubling of values every 48 to 72
hours are indicative of true pregnancy.
 Ultrasonography - confirmatory test.

37. MANAGEMENT
 Can have positive maternal and fetal outcomes with intensive dialysis therapy to
maintain a near-normal serum urea nitrogen level
 ideal goal- 36 hours per week
 Viable goal- more than 20 hours per week, with a serum urea nitrogen target < 50
mg/dL
 Fetal outcomes better with high efficiency dialysis treatment
-prevalence of SGA babies higher n mothers receiving peritoneal dialysis compared
with those receiving hemodialysis (66% vs 31%, respectively).

38. Kidney Transplant Recipients and Pregnancy
 Pregnancy is a sensitizing event leading to formation of anti-HLA antibodies
 KDIGO guidelines state that women should wait for 1 year posttransplantation
before pursuing pregnancy, provided kidney function is stable.
 recent study suggested that waiting 2 years may be prudent

39. MANAGEMENT
 immunosuppressive regimen needs to bemodified
 Usuallya combination of AZA, tacrolimus/cyclosporine, and prednisone.
 Tacrolimus doses often need to be increased substantially in pregnancy
 recent pharmacologic studies have shown that whole-blood measurements of
tacrolimus do not accurately reflect free tacrolimus levels in the setting of
pregnancy- women may experience toxicity with seemingly therapeutic levels.

40. PROGNOSIS
 fertility is improved after transplantation
 risks for pregnancy complications, such as preterm delivery and preeclampsia,
much lower.

41. Kidney donors and pregnancy
 Careful monitoring in pregnancy
 increased risk for preeclampsia
 Garg et al (2015) suggested that kidney donors had 2.4 times increased odds of
having preeclampsia or gestational hypertension (11% vs 5%), but did not have
increased risk for preterm delivery or low birth weight

42. Medications in Pregnancy
 ANTIHYPERTENSIVES
 SAFE- methyldopa, labetalol, or nifedipine.
 UNSAFE- ACE inhibitors and ARB
 ANTICOAGULANTS
 severe nephrotic syndrome, APS, or other thrombophilic conditions.
 Warfarin is contraindicated due to teratogenicity
 LMWH or unfractionated heparin administered as a subcutaneous injection can safely
be given.
 Novel oral anticoagulants are known to cross the placenta and available data about
maternal and fetal outcomes are insufficient

43. IMMUNOSUPPRESANTS IN GOMERULONEPHRITEDES
 Glucocorticoids remain the mainstay of immunosuppressive therapy .
-Prednisone is considered safe during pregnancy due to placental metabolism, with <10% of the
maternal dose found in the fetal circulation.
 Calcineurin inhibitors (ie, cyclosporine and tacrolimus) induce hypertension and gestational
diabetes AND are teratogenic
 Cyclophosphamide and mycophenolate mofetil are teratogenic
 AZA is the drug of choice for pregnant patients previously using mycophenolate mofetil who
require continuation of immunosuppressive therapy.
- AZA treatment ideally should be started 3 months before conception.
 calcineurin inhibitors and AZA have been associated with SGA infants and preterm deliveries.
 Rituximab may be used during pregnancy as part of a chemotherapy regimen for treatment of
incident or recurrent malignancies or severe non malignant hematologic diseases.
- considered safe to administer during the first trimester
- neonatal B-cell depletion has been seen in those who have been exposed in utero during the
third trimester of pregnancy.