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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
Renal Disease and Pregnancy
Matt Hall
Nottingham Renal Unit
SpR Club Belfast
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Sex
Drugs
Rock and roll
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Sex
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Barua M, Hladunewich M, Keunun J et al. Clin J Am Soc Nephrol. 2008;3:392/396
Pregnancy and CKD
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Pregnancy and CKD
Dialysis, 20
CKD 3-4, 240
CKD 1-2, 960
UK, 800000
Approximate number of pregnancies per year in UK
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Maternal and fetal risks
Maternal risks
Is pregnancy going to make my kidney disease worse?
Fetal risks
Will I take home a healthy baby?
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Maternal and fetal risks
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Factors associated with adverse outcomes
Baseline renal function?
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Baseline renal function?
0
10
20
30
40
50
60
70
80
90
100
IUGR Preterm delivery Pre-eclampsia Perinatal death
%
<125
125-180
>180
Dialysis
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Baseline renal function?
0
10
20
30
40
50
60
70
80
Loss of >25% renal functionduring pregnancy
Persistent loss of >25% renalfunction
ESRD after 1 year
%
<125
125-180
>180
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0
20
40
60
80
100
120
140
Baseline serum creatinine
Base
line
seru
m cr
eatin
ine
(μm
ol/l
)
PALRF
No PALRFp=0.027
Baseline renal function?
Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Baseline renal function?
0
20
40
60
80
100
120
Caesarean Section Preterm delivery Small for gestational age Neonatal ICU admission
ControlCKD 1CKD 2CKD 3CKD 4-5
*
*
** **
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Factors associated with adverse outcomes
Baseline renal function - yes
Baseline blood pressure?
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Blood pressure?
Neonatal death
0
5
10
15
20
25
<70 70-80 80-90 >90 or treated
Diastolic blood pressure in early pregnancy (mmHg)
Odd
s ra
tio
Neonatal death risk
Diastolic BP Absolute risk
<70 0.9%
70-80 3.2%
80-90 3.6%
>90 or treated 15.3%
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Slides courtesy of Matt HallNottingham University HospitalsFebruary 2011
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Blood pressure?
0
20
40
60
80
100
120
140
160
Systolic BP Diastolic BP
Mea
n bl
ood
pres
sure
(mm
Hg)
PALRFNo PALRF
p=0.08
p=0.009
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Blood pressure?
• 43 pregnancies in 30 women with CKD (serum creatinine 110 to 490 μmol/l)• Hypertension was present from conception in 26 (60%).• Logistic regression identified uncontrolled hypertension at conception as an independent risk factor for fetal death• RR fetal death with MAP> 105mmHg at conception = 10.5• Accelerated loss of maternal renal function in 7 patients, all of whom had hypertension
• 168 pregnancies in 118 women with IgA nephropathy.• Perinatal mortality 33% in women with BP>140/90 versus 1% with BP<140/90• (Hypertension not identified as a risk factor for progression of maternal disease.)
Jungers P et al. Pregnancy in women with impaired renal function. Clin Nephrol 1997;47(5):218-288Abe S. Pregnancy in IgA nephropathy. Kidney International 1991;40:1098-1102
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Factors associated with adverse outcomes
Baseline renal function - yes
Baseline blood pressure - yes
Proteinuria ?
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Proteinuria
Women without CKD
Second trimester ACR>3mg/mmol
Second trimester ACR>20mg/mmol
OR 1.9 preterm delivery
OR 4.7 preterm deliveryXDiabetes and hypertension
Franceschini N et al. Maternal urine albumin excretion and pregnancy outcome. Am J Kindy Dis. 2005’45(6):1010-1018Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. New Engl J Med 1991;336(4):226-223
Hemmelder MH et al. Proteinuria: a risk factor for pregnancy-related renal function decline in primary glomerular disease? A,m J Kidney Dis 1995;2691):187-192
Women with CKDCreat > 124μmol /l
Proteinuria > 3g/d
Proteinuria < 3g/dNo impact on outcome
Women with CKD
Pregnancy (n=19)
No pregnancy (n=31)
Proteinuria andpregnancy assoc with
PALRF
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Proteinuria?
Imbasciati E et al. AJKD 2007;49:753
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Proteinuria?PALRF
Yes No p value
n 6 21
Maternal age (years) Mean (SD) 33.0 (3.7) 30.4 (3,3) 0.103
Gravidity Median (range) 3 (1-4) 3 (1-5) 0.057
Underlying glomerular disease n (%) 2 (33%) 13 (69%) 0.357