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Pregnancy-induced Nephropathy

Changes during pregnancy

  • Anatomical – ↑size by 1-1.5cm, dilated ureter (due to ↑progesterone which is a muscle relaxant)
  • Physiological
    • GFR increase by 80% in 2nd trimester
    • By 20% in 3rd trimester
    • Decreased BUN + creatnine
    • Proteinuria – 300mg/day
  • Bacteriuria – MC in pregnancy due to delayed emptying, stasis and vesico-ureteral reflux (VUR)
  • Pre-eclampsia – HTN + proteinuria that develops after 20 gestational weeks and resolves with delivery

Acute RF in pregnancy

  • Obstetric complications of ARF – haemorrhage from placenta previa , placental abruption, uterine atony
  • Causes of ARF unique in pregnancy
    • Pre-eclampsia / Eclampsia
    • Severe PPH
    • HELLP syndrome – hemolysis, elevated liver enzymes, low platelet count

Pre-eclampsia

  • Characterised by proteinuria and HTN
  • Due to epithelial damage, causes swollen intra-cap endothelial cells in glomerulus (HALLMARK)
  • RF – very young or old woman, twins, DM, essential HTN
  • CF – HTN (160/110), thrombocytopenia , ↑LDL, ↑liver enzymes, PU>2g, edema, headache, vision disturbance, epigastric pain, HELLP syn
  • Treatment – delivery (definitive), dexamethasone to mature fetal lungs, MgSO4 (to prevent seizures)

Pyelonephritis – risk of PN is higher in pregnancy

  • Treatment– hospitalisation + ceftriaxone
  • If severe (immunocompromised/poor urine ouput) – IV ticarcillin-clavulanate or piperacillin-tazobactam

Diabetic nephropathy

  • ↑risk of pre-eclampsia
  • ACEI contraindicated, nifedipine (CCB) used instead

Asymptomatic bacteriuria – ↑risk of UTI as urine of preg women has higher nutrient content

Thrombotic microangiopathy – fibrin + platelet aggregate in microvasculature in kidney + brain

  • Splitting of glomerular BM, endothelial cell swelling
  • When it primarily affects the kidney it is HUS (usually post partum)
    • Characterised by ↓RBCs, ↓platelets and ARF
    • Etiology – S.dysenteriae, E.coli, S.typhi
    • HUS can develop as a complication of pre-eclampsia
  • When characterised by profound thrombocytopenia + neurological disturbances
    • Thrombotic thrombocytopenic purpura (usually antepartum)

Acute fatty liver of preg – fatty infiltration of hepatocytes

Estimate eGFR is unreliable in pregnancy

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