CRF in Pregnancy

Basics Function of Kidney

To clean the blood of the impurities that naturally build up everyday in the body. The blood tests for creatinine (Cr) and blood urea nitrogen (BUN) are our best blood markers for evaluating kidney function. The normal levels for these are as follows: Cr: 0.4 to 1.4 mg/dl BUN:10 to 20mg/dl A better & precise way of measuring the kidney function is to collect a 24 hour urine sample and measure creatinine and protein.

FIGURE
Increased kidney size

Increased renal blood flow Increased glomerular filtration rate Dilation of urinary tract

Changes in Renal Function During Pregnancy

Renin Uric acid reabsorption

FIGURE

Renal vasodilation Glomerular filtration rate Renal blood flow Serum creatinine Urinary protein

Aldosterone Sodium reabsorption Water reabsorption Urinary calcium Glucosuria Aminoaciduria

A Altered osmoregulation:
Serum sodium and Posm with Osmotic Threshold
for the argenine vasopressin

B Serum chloride levels are

unchanged compared with
women who are not pregnant

release and thirst

Na

Cl

136 mEq/L 3.7 mEq/L

+

104 mEq/L 20 mEq/L

HCO3

C Mild hypokalemia may be

observed due toglomerular filtration rate, urine flow, and aldosterone

D Mild respiratory alkalosis is

associated with small decreases

in plasma bicarbonate

Chronic Renal Failure (CRF)

CRF is by definition distinguished from ARF by the fact that the patient has had loss of kidney function over a more prolonged period of time (more than 3 months and often a process that has been going on for years.

Depending on the severity of chronic damage to the kidneys we separate patients into the following broad categories:

Mild Moderate

60 - 80% of normal function

30 - 60%

Severe

15 - 29%

End stage Renal Disease

< 15 % (these patients require renal replacement therapy: Hemodialysis; Peritoneal Dialysis or Kidney Transplantation)

Pregnancy in Patients with Chronic Renal Failure (CRF)

Can women get pregnant with CRF?

Antenatal Strategy and Decision-Making

Blood pressure control, Fluid balance, Increased hours of dialysis,* and Provision of good nutrition Nutrition# Anemia!

Fetal Surveillance and Timing of delivery cesarean section should be necessary only for purely obstetric reasons. It could be necessary only for purely obstetric reasons. It could be argued; however, that elective cesarean section in all cases would minimize potential problems during labor. In fact, preterm labor is generally the rule and may commence during hemodialysis. The role of cesarean section in this situation needs to be carefully considered.

Does CRF place the fetus at risk?

There are multiple studies that have documented their results in women with CRF who become pregnant. They report their results in pregnant women with varying degrees of CRF and only included those pregnant women who made it past the first trimester. The results show that the higher the Cr (i.e. the more advanced the patients CRF) at time of conception the higher the risk of fetal loss. Interestingly the studies show that the fetal loss is less now then it was in the past. For example: Fetal loss before 1984: 35% Fetal loss after 1984: 9% This is by no means an accurate risk assessment for risk of fetal loss for pregnant women with CRF because it does not take into account the severity of CRF at time of conception. As noted previously the more severe the CRF; higher the risk of fetal loss!

Does CRF place the mother at risk?

There is a marked increase in the risk of superimposed preeclampsia in women with CRF who become pregnant. (65 to 80% develop preeclampsia). In women with CRF who become pregnant, there is a high risk of irreversible worsening of renal disease as a consequence of the pregnancy. It is generally accepted that if the Cr is greater than 2.0mg/ml the risk of incurring irreversible accelerated loss of renal function in the woman is high. Higher the level of Cr (above 2.0mg/ml); greater is the risk of bad outcome.

 INTERRELATIONSHIPS BETWEEN PREGNANCY AND RENAL DISEASE

Impact of pregnancy on renal disease

Impact of renal disease on pregnancy

Hemodynamic changes hyperfiltration Increased proteinuria Intercurrent pregnancy-related illness, eg, preeclampsia Possibility of permanent loss of renal function

Increased risk of preeclampsia Increased incidence of prematurity, intrauterine growth retardation

Can women who have a kidney transplant get pregnant?

Yes indeed, the transplant woman can get pregnant. The risk to the fetus is dependent on how well the transplant kidney is functioning. The standard immunosuppressive drugs (Cyclosporin and azathioprine) are not associated with increases in fetal abnormalities. It has been noted that a longer interval between transplant and pregnancy is associated with decreased risk of low birth weigh and prematurity. In general it is often recommended, to wait for two years after transplant before considering pregnancy.

Counseling and Early Pregnancy Assessment:

A woman should be counseled on the various treatments for renal failure and the potential for optimal rehabilitation. Information regarding potential reproductive capacity must be included. Even after transplantation, stress will still be a major factor in everyday life, which will always have a "baseline of uncertainty". Couples who want a child should be encouraged to discuss all the implications, including the harsh realities of maternal prospects of survival.

Preconception guidelines
Good general health about 2 years since transplantation. Stature compatible with good obstetric outcome. No or minimal proteinuria Absence of hypertension No evidence of graft rejection Absence of pelvicalyceal distension on a recent intravenous urogram Stable renal function with plasma creatinine of 2 mg/100 ml or less (preferably less than 1.5 mg/100 ml). Drug therapy reduced to maintenance levels: prednisone 15 mg/day or less, and azathioprine 2 mg/kg body weight/day or less. Safe doses of cyclosporine-A, have not yet been established because of limited clinical experience, but 5 mg/kg body weight per day or less is quoted anecdotally

What effect does pregnancy have on the transplanted Kidney?

It appears that pregnancy itself does not adversely affect the transplanted kidney as long as the kidney is functioning well at time of conception. If the transplant kidney is not functioning well (i.e. CRF) then the risk of accelerating the loss of renal function with pregnancy is similar to that seen in patients with CRF.

Anesthetic management
Preoperative assessment

ECG

Haemogram

Imaging studies Renal function test

Blood sugar

Urinalysis

Optimization
Fluid balance Biochemical balance (hyperkalemia^ & acidosis) CVS (hypertension, IHD, Pulmonary edema) Respiratory function(Pulmonary edema,effusion) Anemia Dialysis

Anesthetic agents
Induction agents Muscle relaxants
Atracurium is agent of choice, vecuronium and mivacurium can be used
Gallamine should be avoided and pancuronium, alcuronium, pipecuronium, curare and doxacurium should be used with caution.

Opioids Inhalational agents

Non steroidal anti inflammatory agents (NSAIDS) should be avoided

Conduct of Anaesthesia
Premedication

Venous access
Monitoring
If spinal or epidural anaesthesia is being performed fluid preloading should be kept to a minimum and vasoconstrictors used to maintain the blood pressure.

Postoperative Oxygen (2-3 litres/minute nasally or 3-4 litres/minute via face mask) should
be administered for 48 hours after major abdominal or thoracic surgery and 24 hours after intermediate surgery

Summary
In general, prognosis is good if renal dysfunction is minimal and hypertension is absent. There is high fetal wastage at all stages of pregnancy. In the absence of severe maternal problems, the hazards of pregnancy in renal transplant patients are minimal, and successful obstetric outcome is the rule. Acute obstetric renal failure can occur in women with previously healthy kidneys.

strategy of dialysis planning * Maintain BUN < 80 mg/100ml; some would suggest lower, e.g. <50 mg/100ml. IUD of fetus is more likely if levels are much in excess of 80 mg/100 ml, but success has been achieved despite levels of 100 mg/100ml for many weeks. Avoid hypotension during dialysis, which could be damaging to the fetus. In late pregnancy the gravid uterus and the supine posture may aggravate this by decreasing venous return. Ensure good control of blood pressure. Ensure minimal fluctuations in fluid balance and limit volume changes. Scrutinize carefully for preterm labor, as dialysis and uterine contractions are associated. Watch calcium levels closely and avoid hypercalcemia. Limit interdialysis weight gain to about 1 kg until late pregnancy. Also after mid-pregnancy, the classic 0.5 kg/week weight gain should be taken into account when considering dry weight. This should mean a 50% increase in hours and frequency of dialysis. Frequent dialysis renders dietary management and control of weight gain much faster.

 despite more frequent dialysis, relatively free dietary intake should be discouraged. A daily oral intake of 70 gm protein, 1,500 mg calcium, 50 mM potassium and 80 mM sodium is advised, with supplements of dialyzable vitamins. Vitamin D supplements can be difficult to judge in patients who have had parathroidectomy. In addition, the placenta produces hydroxyvitamin D, one reason why oral supplementation may have to be curtailed. All this poses risks for fetal nutrition, plus the fact that the exact impact on the uremic environment is difficult to access. The use of parenteral nutrition supplementation in pregnancy in these gravidas has been advocated. #

Anemia!
patients with severe renal insufficiency are usually anemic. This anemia is usually aggravated further in pregnancy; therefore, blood transfusion may be needed, especially before delivery. Caution is necessary because transfusion may exacerbate hypertension and impair the ability to control circulatory overload, even with extra dialysis. Fluctuations in blood volume can be minimized if packed red cells are transfused during dialysis. Recently rHuEpo has been used in pregnancy without ill effect. It does not have significant transplacental effects. Unnecessary blood sampling should be avoided in the face of anemia and lack of venipunture sites. The protocol for various tests usually performed in a particular unit should be followed strictly, with no more blood removed per venipunture than is absolutely necessary.

 Methods of treating a high serum potassium in an emergency include: Administration of 0.5ml/kg of 10% calcium gluconate (max 20 ml). This has an immediate but transient stabilising effect on the myocardial cells. 50mls of 50% glucose as an intravenous bolus or infusion. Glucose and insulin will produce an immediate migration of potassium into the cells thus reducing the serum level. Blood glucose levels should be closely monitored but unless the patient is diabetic, endogenous insulin will be secreted and maintain normal glycaemia. Alternatively 5-10 units of soluble insulin may be added to the infusion. Apart from the risk of errors which may occur, the patient may also become hypoglycaemic as secretion of endogenous insulin is also stimulated. Administration of 1-2 mmol/kg sodium bicarbonate intravenously over 5-10 minutes. This provides a large sodium and fluid load which may not be desirable. Nebulised salbutamol 2.5 - 5mg will assist in moving K+ into the cells.

Total body potassium levels can then be reduced:

By dialysis. With calcium resonium (0.5 g/kg) 8 hourly either rectally or orally. This takes approximately 12 hours to produce an effect. By the introduction of a low potassium diet^