Obstetric Nephrology: A Case-Based Approach Session (April 11, 2018)

Moderator: Mala Sachdeva

Highlights from this session:

• Differential diagnosis if proteinuria during pregnancy:
  • Proteinuria and hyperfiltration (15^th to 38^th week),
  • Proteinuria and glomerular disease,
  • Proteinuria related to preeclampsia (>20 weeks), or
  • Superimposed preeclampsia.
• Plasma creatinine falls significantly during pregnancy and should not be greater than 0.8 mg/dL. This decrease has clinical significance in that a “normal”  creatinine level in a pregnant patient may actually indicate underlying renal disease.
• Differential diagnosis of worsening HTN during pregnancy:
  • Worsening of hypertension
  • Preeclampsia
  • Other hypertensive disorders of pregnancy
• Women with creatinine < 1.3 to 1.4 seem to do quite well, with relatively insignificant changes in GFR.
• Women with moderate renal impairment: 40% experienced a decline in GFR, 10-20% progressed to ESRD.
• Risk factors for progression of kidney disease during pregnancy:
  • Pre-pregnancy proteinuria (>1g)
  • Pre-pregnancy creatinine (degree of renal dysfunction)
  • Some evidence suggests that proteinuria with any underlying CKD may have more of a detrimental effect on the kidney
  • Extent of comorbidities (hypertension and proteinuria, DM)
  • Worsening hypertension is certainly a poor prognostic indicator and is probably a direct contributor to worsening renal function
  • Urinary tract infection
• There is a 44% preeclampsia rate in ESRD patients getting pregnant.
• 66% of nephrologists stated they are somewhat comfortable to very uncomfortable caring for a pregnant woman on hemodialysis.
• Provide 4 to 4.5 hours of hemodialysis per session  for 6 days/week for the pregnant patient.
• What should one do when an ESRD patient becomes pregnant?
  • Intensify treatment: dialyze 6 days a week for 4 hours each session.
  • Offer counseling from the high-risk OB/nephrology group to discuss risks/benefits involved with the pregnancy and options to terminate or continue the pregnancy.
  • Discontinue any medication that is teratogenic (ACE, ARBS, etc), maintain hemoglobin with ESA, one can use heparin (stopped towards end of pregnancy in case emergent surgery is needed).
  • Prescribe synthetic vitamin D as needed; as placenta converts 25 D3 to 1,25 D3 ,adjust Vitamin D based on PTH, Ca, Phos, Vitamin D levels. Many of these patients have required oral phosphorus supplementation
  • Not recommended to use ddavp at time of delivery if C-section is done as our BUN is usually less than 20 mg/dL
• Perform weekly labs. If dialysis is started before arm access is placed, our access of choice is a graft which we can cannulate within one week of placement (allows removal of hemodialysis catheters early on).
• Changes in our dialysis prescription:
  • Higher Blood Flow Rates for better clearances
  • Maintain a target BUN <20mg/dl
  • Monitor and adjust dry weight weekly, accounting for maternal weight gain and fetal weight gain
  • Higher potassium baths are generally used due to hypokalemia that can result from more frequent dialysis sessions
• Utilize intradialytic fetal monitoring in an outpatient hospital setting once fetus is viable – should any complications arise during the dialysis treatment, the patient is already in the hospital.
• Any sign of an upward blood pressure trend alerts us to the possibility of preeclampsia for which we then suggest to hospitalize the patient for close blood pressure monitoring.
• Assemble a good multidisciplinary team involving internists, obstetricians, nephrologists, nutritionists, and social workers.

– Post prepared by Kenar Jhaveri, AJKD Social Media Advisory Board member. Follow him @kdjhaveri.

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The NKF Spring Clinical Meeting abstracts are available in the April 2018 issue of AJKD. Check out more AJKDBlog coverage of #NKFClinicals!