Ma. Hannah Kariza C. Magpantay, RN.

Renal disease can affect the outcome of pregnancy, pregnancy can affect the progression of pre-existing renal disease, and pregnancy can itself cause renal impairment. The renal system undergoes significant physiological and anatomical changes during a normal pregnancy:

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Renal plasma flow increases by 50-70% in pregnancy (the change is most pronounced in the first two trimesters). There is an increased glomerular filtration rate (GFR), which peaks at about the 13th week of pregnancy and can reach levels up to 150% of normal. Therefore, both urea and creatinine levels are decreased. Increased levels of progesterone at the beginning of pregnancy increase relaxation of arterial smooth muscles and so decrease peripheral vascular resistance, causing a blood pressure fall of approximately 10 mm Hg in the first 24 weeks of pregnancy. A change in tubular function with increased glycosuria also occurs (see Renal function in pregnancy, below).

The anatomical changes are mainly in the collecting system. A dilatation of the ureters and pelvis occurs, which can lead to urinary stasis and an increased risk of developing urinary tract infections (UTIs). There is also an increase in overall kidney size by about 1-1.5 cm. In general, the physiological changes peak by the end of the second trimester and then start to return to pre-pregnancy levels; anatomical changes generally take up to 3 months postpartum to subside.

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Values considered normal when not pregnant may reflect decreased renal function in pregnancy. Creatinine above 75 mol/L and urea above 4.5 mmol/L are indications for further investigation.1 The use of estimated glomerular filtration rate (eGFR) is not recommended in pregnancy.2 Glycosuria is common and does not usually indicate diabetes or impaired glucose tolerance. Urinary protein excretion increases during pregnancy, but never to more than 300 mg/day and, therefore, overt proteinuria is abnormal. Women are at increased risk of urinary tract infection (UTI) because of renal tract dilatation leading to urinary stasis.

Women with +1 (or more) dipstick positive proteinuria in the absence of infection should have the level of proteinuria quantified. Baseline quantification of proteinuria should be by 24-hour collection for urine protein and by protein/creatinine ratio (PCR). PCR alone may be used for follow-up. Pregnant women with persistent proteinuria above 500 mg/day diagnosed before 20 weeks' gestation should be referred promptly to a nephrologist.

Women with nephrotic syndrome should be given thromboprophylaxis with heparin in pregnancy and the puerperium. Lower levels of proteinuria may increase the risk for venous thromboembolism and may also warrant thromboprophylaxis in pregnancy. Isolated microscopic hematuria with structurally normal kidneys does not need to be investigated during pregnancy but should be evaluated if persistent following delivery

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is a group of symptoms including protein in the urine (more than 3.5 grams per day), low blood protein levels, high cholesterol levels, high triglyceride levels, and swelling. Causes, incidence, and risk factors Nephrotic syndrome is caused by various disorders that damage the kidneys, particularly the basement membrane of the glomerulus. This immediately causes abnormal excretion of protein in the urine. The most common cause in children is minimal change disease, while membranous glomerulonephritis is the most common cause in adults. This condition can also occur as a result of infection (such as strep throat, hepatitis, or mononucleosis), use of certain drugs, cancer, genetic disorders, immune disorders, or diseases that affect multiple body systems including diabetes, systemic lupus erythematosus, multiple myeloma, and amyloidosis. It can accompany kidney disorders such as glomerulonephritis, focal and segmental glomerulosclerosis, and mesangiocapillary glomerulonephritis. Nephrotic syndrome can affect all age groups. In children, it is most common from age 2 to 6. This disorder occurs slightly more often in males than females.

Symptoms ` Swelling (edema) is the most common symptom. It may occur: ` In the face and around the eyes (facial swelling) ` In the arms and legs, especially in the feet and ankles ` In the belly area (swollen abdomen) ` Other symptoms include: ` Foamy appearance of the urine ` Weight gain (unintentional) from fluid retention ` Poor appetite ` High blood pressure Signs and tests ` The doctor will perform a physical exam. Laboratory tests will be done to see how well the kidneys are working. They include: ` Creatine - blood test ` Blood urea nitrogen (BUN) ` Creatinine clearance ` Albumin blood test - may be low ` Urinalysis - reveals large amounts of urine protein

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Controlling blood pressure.The goal is to keep blood pressure at or below 130/80 mmHg. Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) are the medicines most often used in this case. Corticosteroids and other drugs that suppress or quiet the immune system may be used. High cholesterol and levels should be treated to reduce the risk of heart and blood vessel problems. Medications to reduce cholesterol and triglycerides may be needed, most commonly statins. A low salt diet may help with swelling in the hands and legs. Water pills (diuretics) may also help with this problem. Low protein diets may or may not be helpful. A moderate-protein diet (1 gram of protein per kilogram of body weight per day) may be suggested. Vitamin D may need to be replaced if nephrotic syndrome is chronic and unresponsive to therapy. Blood thinners may be required to treat or prevent clot formation.

Asymptomatic bacteriuria is found in 2% of sexually active women, and is more common (up to 7%) during pregnancy. Because of the dilatation of the calyces and ureters that occurs in pregnancy, 25% will go on to develop pyelonephritis, which can cause fetal growth restriction, fetal death, and premature labour. Pyelonephritis is common at around 20 weeks and in the puerperium.

Asymptomatic bacteriuria and urinary tract infections (UTIs) in pregnancy should be treated with antibiotics. Antibiotic prophylaxis should be given to women with recurrent bacteriuria or UTIs and kidney disease. 20% of women having pyelonephritis in pregnancy have underlying renal tract abnormalities and an intravenous urogram (IVU) or ultrasound at 12 weeks postpartum should be considered.

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A urinary tract infection, or UTI, is an infection that can happen anywhere along the urinary tract. Urinary tract infections have different names, depending on what part of the urinary tract is infected. Bladder -- an infection in the bladder is also called cystitis or a bladder infection Kidneys -- an infection of one or both kidneys is called pyelonephritis or a kidney infection Ureters -- the tubes that take urine from each kidney to the bladder are only rarely the site of infection Urethra -- an infection of the tube that empties urine from the bladder to the outside is called urethritis

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Urinary tract infections are caused by germs, usually bacteria that enter the urethra and then the bladder. This can lead to infection, most commonly in the bladder itself, which can spread to the kidneys. Women tend to get them more often because their urethra is shorter and closer to the anus than in men. Because of this, women are more likely to get an infection after sexual activity or when using a diaphragm for birth control. Menopause also increases the risk of a UTI. The following also increase your chances of developing a UTI: Diabetes Advanced age (especially people in nursing homes) Problems emptying your bladder completely (urinary retention) A tube called a urinary catheter inserted into your urinary tract Kidney stones Staying still (immobile) for a long period of time (for example, while you are recovering from a hip fracture) Pregnancy Surgery or other procedure involving the urinary tract

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MILD BLADDER AND KIDNEY INFECTIONS Antibiotics taken by mouth are usually recommended because there is a risk that the infection can spread to the kidneys. For a simple bladder infection, you will take antibiotics for 3 days (women) or 7 - 14 days (men). For a bladder infection with complications such as pregnancy or diabetes, OR a mild kidney infection, you will usually take antibiotics for 7 - 14 days. It is important that you finish all the antibiotics, even if you feel better. If you do not finish all your antibiotics, the infection could return and may be harder to treat. Everyone with a bladder or kidney infection should drink plenty of fluids. Taking a single dose of an antibiotic after sexual contact may prevent these infections, which occur after sexual activity. Having a 3-day course of antibiotics at home to use for infections diagnosed based on your symptoms may work for some women. Some women may also try taking a single, daily dose of an antibiotic to prevent infections.

Women with renal disease considering pregnancy should be offered pre-pregnancy assessment and counselling by a multidisciplinary team (which should include an obstetrician, a renal/obstetric physician and a specialist midwife). For women with normal or only mildly decreased prepregnancy renal function (serum creatinine below 125 mol/l), obstetric outcome is usually successful without adverse effects on the long-term course of their disease, but there is an increased risk of antenatal complications such as hypertension and pre-eclampsia (see separate article Hypertension in Pregnancy).

Women with more severe renal impairment are more likely to suffer hypertension , pre-eclampsia or premature labor, and to have a small baby, miscarriage or irreversible decline in renal function in the long-term. Pregnancy is extremely uncommon in women with end-stage renal failure on dialysis, for a variety of reasons; most such women are infertile. Fertility often returns rapidly after a successful renal transplant. If women on dialysis do become pregnant, the outcome is usually poor with a very high risk of miscarriage, severe hypertension, small babies and prematurity. A 50% increase in dialysis is needed. Live birth outcome is only about 50%. Outcome is better for those with renal transplants.

Medications, especially antihypertensive agents, must be reviewed in women with renal disease who wish to get pregnant. Prednisolone, azathioprine, ciclosporin a nd tacrolimus do not appear to be associated with fetal abnormality and should not be discontinued in pregnancy. In pregnant women with renal disease, the target blood pressure should be below 140/90 mm Hg. Women with kidney disease should be offered lowdose aspirin as prophylaxis against pre-eclampsia, with treatment starting within the first trimester.

Women found, or suspected to have, renal disease in pregnancy should be referred to a nephrologist. ` Pregnancy itself can cause acute renal failure and renal disease can present for the first time during pregnancy. ` Acute (sudden) kidney failure is the sudden loss of the ability of the kidneys to remove waste and concentrate urine without losingelectrolytes.

Acute renal failure in pregnancy may be due to various causes, including:

Septicaemia, e.g. septic abortion, pyelonephritis. Haemolysis, e.g. sickling crisis, malaria. Hypovolaemia, e.g. pre-eclampsia, antepartum haemorrhage, intrapartum or postpartum haemorrhage, disseminated intravascular coagulation (DIC), abortion.

Acute tubular necrosis (ATN) Autoimmune kidney disease, including:

Acute nephritic syndrome Interstitial nephritis

Hemolytic-uremic syndrome Idiopathic thrombocytopenic thrombotic purpura (ITTP) Malignant hypertension Transfusion reaction Scleroderma
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Decreased blood flow due to very low blood pressure, which can result from:
Burns Dehydration Hemorrhage Injury Septic shock Serious illness Surgery

Infections that directly injure the kidney, such as:

Acute pyelonephritis Septicemia

Pregnancy complications, including:

Placenta abruptio Placenta previa

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Disorders that cause clotting within the kidney's blood vessels:

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Once the cause is found, the goal of treatment is to restore kidney function and prevent fluid and waste from building up in the body while the kidneys heal. Usually, you have to stay overnight in the hospital for treatment. The amount of liquid you eat (such as soup) or drink will be limited to the amount of urine you can produce. You will be told what you may and may not eat to reduce the buildup of toxins normally handled by the kidneys. Your diet may need to be high in carbohydratesand low in protein, salt, and potassium. You may need antibiotics to treat or prevent infection. Diuretics ("water pills") may be used to help the kidneys lose fluid. Calcium or glucose/insulin will be given through a vein to help avoid dangerous increases in blood potassium levels. Dialysis may be needed, and can make you feel better. It is not always necessary, but it can save your life if your potassium levels are dangerously high. Dialysis will also be used if your mental status changes, you stop urinating, develop pericarditis, retain too much fluid, or cannot eliminate nitrogen waste products from your body.

Reflux nephropathy:
Prophylactic antibiotics are required. Potential for inheritance.

Reflux nephropathy is a condition in which the kidneys are damaged by the backward flow of urine into the kidney.

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Urine flows from each kidney, through tubes called ureters, and into the bladder. When the bladder is full, it squeezes and sends the urine out through your urethra. None of the urine should flow back into the ureter when the bladder is squeezing. Each ureter has a one-way valve where it enters the bladder, preventing urine from flowing back up the ureter. But in some people, the urine flows back up to the kidney. This is called reflux. Over time, the kidneys may be damaged or scarred by this reflux. This is called reflux nephropathy Reflux can occur in people whose ureters do not attach properly to the bladder or if the valves do not work well. Children may be born with this problem or other birth defects of the urinary system that cause reflux nephropathy. Reflux nephropathy can occur with other conditions that lead to a blockage of urine flow, including: Bladder outlet obstruction Bladder stones Neurogenic bladder, which can occur in people with multiple sclerosis Reflux nephropathy also can occur from swelling of the ureters after a kidney transplant or trauma to the ureter. The risk factors include a personal or family history of reflux, abnormalities of the urinary tract, and repeat urinary tract infections.

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Symptoms Some people can have no symptoms from reflux nephropathy. The problem may be found when different tests are done for other reasons. If symptoms do occur, they might be similar to those of a urinary tract infection, nephrotic syndrome, or chronic kidney failure. High blood pressure may be the only symptom.

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Antibiotics taken every day to prevent infections Careful watching Repeated urine cultures Yearly ultrasound of the kidneys Controlling blood pressure is the most important measure to delay kidney damage. Therefore, the doctor may prescribe medicines to control high blood pressure. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) are used. SurgicalCauses, incidence, and risk factors therapy is reserved for children who fail medical therapy. More severe reflux may require surgery, especially in children who do not respond to medical therapy. Surgery to place the ureter(s) back into the bladder can be done to stop reflux nephropathy. More severe reflux may require surgery, such as the following: Ureteral reimplantation Reconstructive repair These surgeries result in less frequent and less severe urinary tract infections. If needed, patients will be treated for chronic kidney disease.

Systemic lupus erythematosus:

High risk of spontaneous abortion. May need immunosuppressant therapy. Problems for the fetus (e.g. neonatal lupus, heart block).

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Diabetic nephropathy:
Deterioration of hypertension. Increased risk of pre-eclampsia. Accelerated decline in renal function

Diabetic nephropathy is kidney disease or damage that results as a complication of diabetes.

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The exact cause of diabetic nephropathy is unknown, but it is believed that uncontrolled high blood sugar leads to the development of kidney damage, especially when high blood pressure is also present. In some cases, your genes or family history may also play a role. Not all persons with diabetes develop this condition. Each kidney is made of hundreds of thousands of filtering units called nephrons. Each nephron has a cluster of tiny blood vessels called a glomerulus. Together these structures help remove waste from the body. Too much blood sugar can damage these structures, causing them to thicken and become scarred. Slowly, over time, more and more blood vessels are destroyed. The kidney structures begin to leak and protein (albumin) begins to pass into the urine. Persons with diabetes who have the following risk factors are more likely to develop this condition: African American, Hispanic, or American Indian origin Family history of kidney disease or high blood pressure Poor control of blood pressure Poor control of blood sugars Type 1 diabetes before age 20 Smoking Diabetic nephropathy generally goes along with other diabetes complications including high blood pressure, retinopathy, and blood vessel changes.

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Early stage diabetic nephropathy has no symptoms. Over time, the kidney's ability to function starts to decline. Symptoms develop late in the disease and may include: Fatigue Foamy appearance or excessive frothing of the urine Frequent hiccups General ill feeling Generalized itching Headache Nausea and vomiting Poor appetite Swelling of the legs Swelling, usually around the eyes in the mornings; general body swelling may occur with late-stage disease Unintentional weight gain (from fluid buildup)

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The goals of treatment are to keep the kidney disease from getting worse and prevent complications. This involves keeping your blood pressure under control (under 130/80). Controlling high blood pressure is the most effective way of slowing kidney damage from diabetic nephropathy. Your doctor may prescribe the following medicines to lower your blood pressure and protect your kidneys from damage: Angiotensin-converting enzyme (ACE) inhibitors Angiotensin receptor blockers (ARBs) These drugs are recommended as the first choice for treating high blood pressure in persons with diabetes and for those with signs of kidney disease. It is also very important to control lipid levels, maintain a healthy weight, and engage in regular physical activity. You should closely monitor your blood sugar levels. Doing so may help slow down kidney damage, especially in the very early stages of the disease. Your can change your diet to help control your blood sugar. Depending on how poorly your kidneys are working, your doctor may limit the amount of protein in your diet. Your doctor may also prescribe medications to help control your blood sugar. Your dosage of medicine may need to be adjusted from time to time. As kidney failure gets worse, your body removes less insulin, so smaller doses may be needed to control glucose levels. Urinary tract and other infections are common and can be treated with appropriate antibiotics. Dialysis may be necessary once end-stage kidney disease develops. At this stage, a kidney transplant may be considered. Another option for patients with type 1 diabetes is a combined kidney-pancreas transplant.

Kidney transplant recipient:

Increased risk of miscarriage in the first trimester. Risk from some immunosuppressants (e.g. mycophenolate mofetil). Increased risk of hypertension. Premature delivery.

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