Avoiding Kidney Injury Obstetric Patients Objectives Discuss incidence and impact of acute kidney injury chronic kidney disease inobstetric patients.
Review the pathophysiology related to pregnancy and risk for developing AKI Summarize neuraxial and general anesthesia recommendations supported by theliterature for obstetric patients with AKI or CKD For more information For a more in depth overview of kidney disease including staging and definitions .
reference MPOG Avoiding Kidney Injury Overview Pathophysiology Definitions For other specialty specific recommendations reference the following sections of the Avoiding Kidney Injury Pediatrics Avoiding Kidney Injury Cardiac Avoiding Kidney Injury Recommendations for Adult Surgical Patients.
Kidney Disease in Obstetric Patients Kidney disease is an independent riskfactor for maternal and fetal morbidity andmortality1 Multiple renal physiologic changes in.
AKI in pregnancy is rare hard to define anddifficult to measure Renal Function Changes in Pregnancy 2 3 Renal Blood Flow Plasma osmolality.
Protein excretion GFR 30 50 Scr and plasma sodium Uric Acid Excretion up to 300mg 24h Renal Function Changes in Pregnancy 3 4 5 size by 1.
IntravascularProgesterone causessmooth musclerelaxation Kidney volume Stasis resulting in.
increases up to 30 increased risk ofand dilation ofurinary tractcalyces pelvis and.
Gravid uterus causes ureters occurspartial ureteralobstruction CKD in Pregnancy CKD in Obstetric Patients.
CKD is estimated to affect 3 of all pregnant women6 5x more likely to experience7 Gestational HTNMaternal Outcomes Preeclampsia Eclampsia.
Maternal Mortality 2x greater risk of adverse fetalFetal Outcomes Risk proportional to degree ofmaternal CKD8 9 CKD in Pregnancy.
Obstetric complications increase proportionally with the extent of the mother spreexisting renal disease and hypertension 10 Women with CKD at increased risk for preeclampsia and preterm delivery 11 There is a 4 7x greater risk of progression to ESRD for patients with CKD that developpreeclampsia12.
Maternal Renal Function Associated Risks 11 13 14 15 16 17Mild elevated creatinine 1 2 1 4mg dL Small risk for decline in renal functionModerate renal insufficiency 1 4 2 5mg dL 20 30 increased risk of preeclampsia and pretermSevere renal insufficiency Cr 2 5mg dL 70 experience preterm delivery 40 experience lossof renal function during pregnancy or postpartum.
leading to dialysis Perioperative Management of Obstetric patients with CKDPeriop Eval Include assessment of changes to renal function and related systems18 Consult nephrology team to assist early in pregnancy19.
Anesthetic Management Dependent on severity of CKD 18 Typically euvolemic patients with stable mild to moderate renal insufficiency and wellcontrolled HTN do well with minimal special interventions 11 Dialysis dependent patients present greater anesthetic challenge 11.
Nephrotoxic Drugs Avoid nephrotoxic drugs in patients with residual kidney function11 Neuraxial Anesthesia Considerations for Obstetric patients with CKD Determine fluid status before anesthesia11 If euvolemic treat hypotension with a vasopressor instead of fluids to reduce risk of fluid overload.
Assess coagulation status At risk for abnormal bleeding11 May have residual heparin from HD catheter that precludes regional anesthesia 11 Documentation of pre existing neuropathy prior to neuraxial anesthesia 18 Insufficient evidence to recommend spinal vs epidural 18.
Intraop Management of Obstetric patients with CKD Non invasive BP monitoring appropriate for early CKD with well controlled HTN 11 Pad and protect HD fistula no blood pressures on that arm18 Check serum K before OR succinylcholine will cause a 0 5 0 7 mEq L increase 18 Magnesium sulfate prolongs NMB 11.
Morphine and meperidine can cause accumulation of toxic metabolites in renal failure Fentanyl sufentanil remifentanil are considered safe to use in renal failure 18 21 Neuraxial opioids are a good choice for postop pain relief if not contraindicated 18 22 NSAIDs may worsen renal function 11 23 AKI in Pregnancy.
AKI In Pregnancy Causes of AKI In developing countries septic abortions are the most prevalent cause of pregnancy related AKI24 25 In developed countries the most common causes are severe preeclampsia eclampsia acutepyelonephritis of pregnancy and bilateral renal cortical necrosis26 27.
The majority of women who experience AKI in pregnancy have comorbid conditions orpregnancies complicated by kidney disease hypertension diabetes preeclampsia HELLP syndrome hemorrhage or infections28 Pregnancy Specific Causes of AKI 29 2Early Causes 20 weeks Late Causes 20 weeks .
Pre Renal Hemorrhage abortion ectopic pregnancy Hemorrhage antepartum placenta previa placentalSepsis Septic Shock abortion retained products abruption placenta accreta postpartum atony of conception pyelonephritis etc trauma uterine rupture Hypovolemia d t hyperemesis gravidarum Sepsis pyelonephritis chorioamnionitis puerperalIntrinsic Acute tubular necrosis d t septic abortion Preeclampsia.
HELLP Syndrome most common cause of AKI inpregnancy Acute fatty liver disease of pregnancyThrombotic thrombocytopenic purpura TTP Atypical hemolytic uremic syndrome aHUS .
Post Renal n a Uteropelvic obstruction gravid uterus masses renalstone normally seen with a pelvic pathology Surgical ureter damage post surgical obstruction AKI in Pregnancy Non pregnant AKI definitions ie KDIGO not appropriate during pregnancy.
No consensus definition of AKI in pregnancy making it difficult to establish incidence Acute renal failure was found in 4 52 per 10 000 US births from 2008 200930Non First Second Third 31pregnant adult Trimester Trimester TrimesterNormal Ref Range 05 09 0 4 0 7 0 4 0 8 0 4 0 9.
Creatinine mg dL SCr 1 1mg dL or doubling SCr in the absence of other renalACOG Renal Insufficiency diseaseDefinition32Definition used as part of diagnostic criteria for severe preeclampsia.
AKI in PregnancyIncreased renal function may mask early AKI symptoms 2Lab values considered normal in non pregnant women may indicateworsening renal function in pregnant patients 29Increasing proteinuria in pregnant patients with CKD may be normal in the.
progression of pregnancy and not indicative of worsening functionDifficult to establish baseline GFR in pregnancy without 24h collection 2Oliguria in preeclampsia is part of disease pathology in response tointravascular depletion and may not indicate worsening renal fn 29 Management of AKI in Pregnancy.
Management of AKI in pregnancy should focus on management of the cause of AKIand consider multiple causes2 Should also consider non pregnancy related causes of AKI 29 Renal biopsy rarely indicated usually delayed until after delivery29 Should use multidisciplinary approach.
Renal therapy2 Low dose dopamine Not recommended Furosemide Not recommended Fenoldopam Needs further research N acytylcysteine Needs further research.
Albumin Needs further research Clinical Assessment of Pregnant Women with Raised Creatinine 29 AKI in Pregnancy Management Consider transfer to specialty center if not responding to initial conservativemeasures29.
Review medications and discontinue nephrotoxic drugs if possible 29 Renally cleared medications may need adjustment A single loading dose of magnesium sulfate for preeclampsia considered safe even in renal failure Should optimize status before delivery18 If BUN 80 mg dL or K 5 5mEq L dialysis should be performed before elective vaginal or c section.
Neuraxial anesthesia is preferred to general anesthesia 18 Considerations for general anesthesia in the setting of AKI similar to that for CKD Obstetric Kidney Disease Summary Kidney disease in pregnancy increases risk of adverse outcomes to both the mother and the fetus Perioperative management of obstetric patients with CKD should consider CKD staging and related.
physiologic changes Intraop management of CKD should consider individual need for CVP monitoring dependent onfluid status adjustments of anesthetic medications as appropriate and protection of HD fistula if Multiple renal physiologic changes in pregnancy make AKI in pregnancy hard to define and difficultto measure Lab values considered normal in non pregnant women may be indicative of AKI in.
Obstetric AKI management should be individualized to consider the cause of the AKI Considerations should be made to discontinue nephrotoxic drugs as appropriate and monitorbleeding risk related to neuraxial anesthesia References1 Fischer Michael J Susie D Lehnerz Jeff R Hebert and Chirag R Parikh 2004 Kidney Disease Is an Independent Risk Factor.
for Adverse Fetal and Maternal Outcomes in Pregnancy American Journal of Kidney Diseases The Official Journal of the NationalKidney Foundation 43 3 415 23 2 Van Hook James W 2014 Acute Kidney Injury during Pregnancy Clinical Obstetrics and Gynecology 57 4 851 61 3 Podymow Tiina Phyllis August and Ayub Akbari 2010 Management of Renal Disease in Pregnancy Obstetrics andGynecology Clinics of North America 37 2 195 210 .
4 Christensen T J G Klebe V Bertelsen and H E Hansen 1989 Changes in Renal Volume during Normal Pregnancy ActaObstetricia et Gynecologica Scandinavica 68 6 541 43 5 Kuczkowski Krzysztof M and Laurence S Reisner 2003 Anesthetic Management of the Parturient with Fever and Infection Journal of Clinical Anesthesia 15 6 478 88 6 Webster Philip Liz Lightstone Dianne B McKay and Michelle A Josephson 2017 Pregnancy in Chronic Kidney Disease and.
Kidney Transplantation Kidney International 91 5 1047 56 7 Nevis Immaculate F Angela Reitsma Arunmozhi Dominic Sarah McDonald Lehana Thabane Elie A Akl MichelleHladunewich et al 2011 Pregnancy Outcomes in Women with Chronic Kidney Disease A Systematic Review Clinical Journal ofthe American Society of Nephrology CJASN 6 11 2587 98 References.
8 Alsuwaida Abdulkareem Dujanah Mousa Ali Al Harbi Mohammed Alghonaim Sumaya Ghareeb and Mona N Alrukhaimi 2011 Impact of Early Chronic Kidney Disease on Maternal and Fetal Outcomes of Pregnancy The Journal of Maternal Fetal Neonatal Medicine The Official Journal of the European Association of Perinatal Medicine the Federation of Asia and OceaniaPerinatal Societies the International Society of Perinatal Obstetricians 24 12 1432 36 9 Ramin Susan M Alex C Vidaeff Edward R Yeomans and Larry C Gilstrap 3rd 2006 Chronic Renal Disease in Pregnancy .
Obstetrics and Gynecology 108 6 1531 39 10 Lindheimer Marshall D and Adrian I Katz 1994 9 Gestation in Women with Kidney Disease Prognosis and Management Bailli re s Clinical Obstetrics and Gynaecology 8 2 387 404 11 Chinnappa V S Ankichetty P Angle and S H Halpern 2013 Chronic Kidney Disease in Pregnancy International Journal ofObstetric Anesthesia 22 3 223 30 .
12 Vikse Bj rn Egil Lorentz M Irgens Torbj rn Leivestad Rolv Skjaerven and Bjarne M Iversen 2008 Preeclampsia and theRisk of End Stage Renal Disease The New England Journal of Medicine 359 8 800 809 13 Katz A I J M Davison J P Hayslett E Singson and M D Lindheimer 1980 Pregnancy in Women with Kidney Disease Kidney International 18 2 192 206 14 Abe S Y Amagasaki K Konishi E Kato H Sakaguchi and S Iyori 1985 The Influence of Antecedent Renal Disease on.
Pregnancy American Journal of Obstetrics and Gynecology 153 5 508 14 References15 Jungers P P Houillier D Forget M Labrunie H Skhiri I Giatras and B Descamps Latscha 1995 Influence of Pregnancy onthe Course of Primary Chronic Glomerulonephritis The Lancet 346 8983 1122 24 16 Abe S 1991 Pregnancy in IgA Nephropathy Kidney International 40 1098 1102 .
17 Chopra Seema Vanita Suri Neelam Aggarwal Meenakshi Rohilla Anish Keepanasseril and H S Kohli 2009 Pregnancy inChronic Renal Insufficiency Single Centre Experience from North India Archives of Gynecology and Obstetrics 279 5 691 95 18 Katz Daniel and Yaakov Beilin 2019 Renal Disease In Chestnut s Obstetric Anesthesia Principles and Practice 6th Edition edited by David Chestnut Cynthia Wong Lawrence Tsen D Ngan Kee Warwick Yaakov Beilin Jill Mhyre Brian T Bateman andNaveen Nathan 1215 30 Elsevier .
19 Wiles Kate Lucy Chappell Katherine Clark Louise Elman Matt Hall Liz Lightstone Germin Mohamed et al 2019 ClinicalPractice Guideline on Pregnancy and Renal Disease BMC Nephrology 20 1 401 Review medications and discontinue nephrotoxic drugs if possible29. Renally cleared medications may need adjustment. A single loading dose of magnesium sulfate for preeclampsia considered safe even in renal failure. Should optimize status before delivery18

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