History

Fact Explanation
Symptoms of urinary tract infection (UTI) UTI in pregnancy can cause ascending infection, pyelonephritis and renal failure. Patients present with dysuria, increased frequency of micturition and nocturia. [3]
Symptoms of urinary calculi Urinary calculi can cause obstructive uropathy and renal failure. Severe pain radiating from loin to groin and hematuria can be the presenting complains. [4]
History of subfertility Females with chronic kidney disease have subfertility. [5]
Hematuria Hematuria can occur in renal cortical necrosis, which is rare but important cause for acute renal failure. [6]
Flank pain Flank pain can occur with pyelonephritis and also with renal cortical necrosis. [7]
Reduced urine output Acute renal failure can present with reduced or absent urine output. [3]
Fever Patients with pyelonephritis can present with fever. [7]
History of hyperemesis gravidarum Patients with hyperemesis gravidarum can develop pre-renal renal failure due to hypovolemia. Usually this resolves with adequate rehydration and replacement of lost electrolytes. [3]
History of miscarriage Females who has had an miscarriage either spontaneous of septic can have acute tubular necrosis due to hemorrhage and or sepsis. [2]
History of preeclampsia Preeclampsia causes renal failure in the latter part of the pregnancy. Elevated blood pressure as well as the development of HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome both contribute for the renal injury. [8,9]
History of abruptio placentae Uterine hemorrhage with abruptio placentae can cause acute tubular injury. [3]
Symptoms suggestive of acute fatty liver of pregnancy Acute fatty liver of pregnancy can also pregress to the development of acute kidney injury. Patients usually present with pain in the right hypochondrium, anorexia, nausea, vomiting and jaundice. This usually occurs after 34 weeks of gestation. [1]
Symptoms of post-partum kidney injury Post-partum kidney injury occurs during the post-partum period. Post-partum hemorrhage and puerperal sepsis can lead to acute kidney injury. Severe hypertension, hemolytic anemia and thrombocytopenia are common associated features. [2]
Risk factors Presence of systemic lupus erythematosus and diabetes mellitus may indicate the presence of underlying renal impairment. [10]
References
  1. DE OLIVEIRA CV, MOREIRA A, BAIMA JP, FRANZONI LD, LIMA TB, YAMASHIRO FD, COELHO KY, SASSAKI LY, CARAMORI CA, ROMEIRO FG, SILVA GF. Acute fatty liver of pregnancy associated with severe acute pancreatitis: A case report World J Hepatol [online] 2014 Jul 27, 6(7):527-531 [viewed 29 August 2014] Available from: doi:10.4254/wjh.v6.i7.527
  2. GODARA SM, KUTE VB, TRIVEDI HL, VANIKAR AV, SHAH PR, GUMBER MR, PATEL HV, GUMBER VM. Clinical profile and outcome of acute kidney injury related to pregnancy in developing countries: A single-center study from India. Saudi J Kidney Dis Transpl [online] 2014 Jul-Aug, 25(4):906-11 [viewed 29 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24969215
  3. MACHADO SUSANA, FIGUEIREDO NUNO, BORGES ANDREIA, SãO JOSé PAIS MARIA, FREITAS LUíS, MOURA PAULO, CAMPOS MáRIO. Acute kidney injury in pregnancy: a clinical challenge. JN [online] December, 25(1):19-30 [viewed 29 August 2014] Available from: doi:10.5301/jn.5000013
  4. GEORGESCU D, MULţESCU R, GEAVLETE B, GEAVLETE P, CHIUţU L. Ureteroscopy -- first-line treatment alternative in ureteral calculi during pregnancy? Chirurgia (Bucur) [online] 2014 Mar-Apr, 109(2):229-32 [viewed 29 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24742417
  5. RATHI M, RAMACHANDRAN R. Sexual and gonadal dysfunction in chronic kidney disease: Pathophysiology. Indian J Endocrinol Metab [online] 2012 Mar, 16(2):214-9 [viewed 29 August 2014] Available from: doi:10.4103/2230-8210.93738
  6. ALAMEEL TURKI, WEST MICHAEL. Tranexamic Acid Treatment of Life-Threatening Hematuria in Polycystic Kidney Disease. International Journal of Nephrology [online] 2011 December, 2011:1-3 [viewed 29 August 2014] Available from: doi:10.4061/2011/203579
  7. ARTERO A, ALBEROLA J, EIROS JM, NOGUEIRA JM, CANO A. Pyelonephritis in pregnancy. How adequate is empirical treatment? Rev Esp Quimioter [online] 2013 Mar, 26(1):30-3 [viewed 29 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23546459
  8. WANG IK, MUO CH, CHANG YC, LIANG CC, CHANG CT, LIN SY, YEN TH, CHUANG FR, CHEN PC, HUANG CC, WEN CP, SUNG FC, MORISKY DE. Association between hypertensive disorders during pregnancy and end-stage renal disease: a population-based study. CMAJ [online] 2013 Feb 19, 185(3):207-13 [viewed 29 August 2014] Available from: doi:10.1503/cmaj.120230
  9. EILAND E, NZERUE C, FAULKNER M. Preeclampsia 2012. J Pregnancy [online] 2012:586578 [viewed 29 August 2014] Available from: doi:10.1155/2012/586578
  10. MATHIESEN ER, RINGHOLM L, FELDT-RASMUSSEN B, CLAUSEN P, DAMM P. Obstetric nephrology: pregnancy in women with diabetic nephropathy--the role of antihypertensive treatment. Clin J Am Soc Nephrol [online] 2012 Dec, 7(12):2081-8 [viewed 29 August 2014] Available from: doi:10.2215/CJN.00920112

Examination

Fact Explanation
Fever Patients with associated urinary tract infection or pyelonephritis can be febrile. [1]
Blood pressure Blood pressure is elevated in the presence of chronic renal disease and also with pre-eclampsia. Hypotension can be found in excessive hemorrhage after miscarriage and after delivery (post-partum hemorrhage) and in sepsis. [2]
Renal angle tenderness Pyelonephritis and renal cortical necrosis can result in renal angle tenderness. [1]
Stigmata of chronic kidney disease Pallor, generalized edema, half and half nails, increased pigmentation of the skin, scratch marks, purpura and gynecomastia. [3,4]
References
  1. ARTERO A, ALBEROLA J, EIROS JM, NOGUEIRA JM, CANO A. Pyelonephritis in pregnancy. How adequate is empirical treatment? Rev Esp Quimioter [online] 2013 Mar, 26(1):30-3 [viewed 29 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23546459
  2. TEDLA FM, BRAR A, BROWNE R, BROWN C. Hypertension in Chronic Kidney Disease: Navigating the Evidence Int J Hypertens [online] :132405 [viewed 29 August 2014] Available from: doi:10.4061/2011/132405
  3. DMITRIEVA OLGA, DE LUSIGNAN SIMON, MACDOUGALL IAIN C, GALLAGHER HUGH, TOMSON CHARLES, HARRIS KEVIN, DESOMBRE TERRY, GOLDSMITH DAVID. Association of anaemia in primary care patients with chronic kidney disease: cross sectional study of quality improvement in chronic kidney disease (QICKD) trial data. Array [online] 2013 December [viewed 29 August 2014] Available from: doi:10.1186/1471-2369-14-24
  4. THOMAS EA, PAWAR B, THOMAS A. A prospective study of cutaneous abnormalities in patients with chronic kidney disease. Indian J Nephrol [online] 2012 Mar, 22(2):116-20 [viewed 29 August 2014] Available from: doi:10.4103/0971-4065.97127

Differential Diagnoses

Fact Explanation
Preeclampsia Preeclampsia should be considered as a differential diagnosis if proteinuria is detected after 20th week of gestation. [2]
Acute fatty liver of pregnancy Acute fatty liver of pregnancy occurs during the third trimester of pregnancy. Anorexia, nausea, vomiting, abdominal pain, and jaundice are the common presenting complains. Characteristically acute fatty liver of pregnancy is not associated with hypertension. [1]
Hemolytic-uremic syndrome (HUS) HUS is a cause for acute kidney injury, which occurs commonly during the first trimester. [3]
Thrombotic thrombocytopenic purpura (TTP) TTP is another cause for acute kidney injury. Patients present with symptoms of acute renal failure. Plasmapheresis, and steroids are available treatment options. [4]
References
  1. DE OLIVEIRA CV, MOREIRA A, BAIMA JP, FRANZONI LD, LIMA TB, YAMASHIRO FD, COELHO KY, SASSAKI LY, CARAMORI CA, ROMEIRO FG, SILVA GF. Acute fatty liver of pregnancy associated with severe acute pancreatitis: A case report World J Hepatol [online] 2014 Jul 27, 6(7):527-531 [viewed 29 August 2014] Available from: doi:10.4254/wjh.v6.i7.527
  2. POWE C. E., LEVINE R. J., KARUMANCHI S. A.. Preeclampsia, a Disease of the Maternal Endothelium: The Role of Antiangiogenic Factors and Implications for Later Cardiovascular Disease. Circulation [online] December, 123(24):2856-2869 [viewed 29 August 2014] Available from: doi:10.1161/CIRCULATIONAHA.109.853127
  3. WANG YQ, WANG J, JIANG YH, YE RH, ZHAO YY. A case of severe preeclampsia diagnosed as post-partum hemolytic uremic syndrome. Chin Med J (Engl) [online] 2012 Mar, 125(6):1189-92 [viewed 29 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22613554
  4. GONZáLEZ-MESA E, NARBONA I, BLASCO M, COHEN I. Unfavorable course in pregnancy-associated thrombotic thrombocytopenic purpura necessitating a perimortem Cesarean section: a case report. J Med Case Rep [online] 2013 Apr 29:119 [viewed 29 August 2014] Available from: doi:10.1186/1752-1947-7-119

Investigations - for Diagnosis

Fact Explanation
Full blood count Iron deficiency anemia and thrombocytopenia can be observed in the presence of chronic kidney disease. Pyelonephritis causes elevated neutrophills. [4,5,6]
Serum creatinine [1] Serum creatinine is elevated in renal failure.
Serum electrolytes Altered electolyte balance with elevated potassium can be observed in the presence of renal impairment. [6]
Urinary protein Presence of protein in urine (more than 3g/day) from the first trimester onward indicates intrinsic renal disease. [7]
Urine microscopy Microscopic examination of a urine sample shows granular casts in acute tubular necrosis. In a fresh urine sample, presence of leukocytes (10 or more leukocytes/mm3) and leukocyte casts can be detected in the presence of a urinary tract infection (UTI). Urinary leukocyte excretion rate of more than 400,000 leukocytes/hour is another useful indicator of UTI. Gram staining and demonstration of bacteria of fungi allows quick diagnosis of UTI. Gram staining has relatively low sensitivity and it detects the organisms only if it is more than 10*5 colony forming units/mL. [2]
Urine culture Urine culture is helpful in diagnosing urinary tract infections, asymptomatic bacteriuria and also isolating the pathogenic organism. Presencr of 105 or more colony forming units/mL of urine and symptoms of a UTI is indicative of UTI. In the absence of symptoms if the urine culture shows 105 or more colony forming units/mL it is called asymptomatic bacteriuria. [2,3]
Urine nitrite test In the presence of Enterobacteria nitrate in urine is converted in to nitrite, which can be detected by the test. This test has very low usefulness as it only identifies the pathogens in the family of Enterobacteriaceae. Early morning urine samples should be used for the test as these bacteria take at least 4 hours to convert nitrate in to nitrite. [2]
Leukocyte esterase test Positive leukocyte esterase test indicates pyuria. This test has low sensitivity, specificity and low positive predictive value of UTI. [2]
Fractional excertion of sodium Fractional excretion of sodium is lower than 1% in prerenal renal failure, whereas it is more than 3% in an intrinsic renal failure. [8]
Glomerular filtration rate (GFR) Usually GRF increases up to 50% of pre-pregnancy values during the pregnancy. GFR is reduced in the presence of acute pyelonephritis. [1]
Ultrasound scan Ultrasound scan is useful in the diagnosis of urolithiasis and pyelonephritis as X-ray and other investigations with exposure to ionizing radiation is harmful to the fetus. [9]
References
  1. SMITH MC, MORAN P, WARD MK, DAVISON JM. Assessment of glomerular filtration rate during pregnancy using the MDRD formula. [online] 2007 October, 115(1):109-112 [viewed 29 August 2014] Available from: doi:10.1111/j.1471-0528.2007.01529.x
  2. WILSON MICHAEL L., GAIDO LORETTA. Laboratory Diagnosis of Urinary Tract Infections in Adult Patients. CLIN INFECT DIS [online] 2004 April, 38(8):1150-1158 [viewed 29 August 2014] Available from: doi:10.1086/383029
  3. IMADE PE, IZEKOR PE, EGHAFONA NO, ENABULELE OI, OPHORI E. Asymptomatic bacteriuria among pregnant women N Am J Med Sci [online] 2010 Jun, 2(6):263-266 [viewed 29 August 2014] Available from: doi:10.4297/najms.2010.2263
  4. DMITRIEVA OLGA, DE LUSIGNAN SIMON, MACDOUGALL IAIN C, GALLAGHER HUGH, TOMSON CHARLES, HARRIS KEVIN, DESOMBRE TERRY, GOLDSMITH DAVID. Association of anaemia in primary care patients with chronic kidney disease: cross sectional study of quality improvement in chronic kidney disease (QICKD) trial data. Array [online] 2013 December [viewed 29 August 2014] Available from: doi:10.1186/1471-2369-14-24
  5. DORGALALEH A, MAHMUDI M, TABIBIAN S, KHATIB ZK, TAMADDON GH, MOGHADDAM ES, BAMEDI T, ALIZADEH S, MORADI E. Anemia and thrombocytopenia in acute and chronic renal failure. Int J Hematol Oncol Stem Cell Res [online] 2013, 7(4):34-9 [viewed 29 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24505541
  6. MODI MP, VORA KS, PARIKH GP, SHAH VR, MISRA VV, JASANI AF. Anesthetic management in parturients with chronic kidney disease undergoing elective Caesarean delivery: Our experience of nine cases Indian J Nephrol [online] 2014, 24(1):20-23 [viewed 29 August 2014] Available from: doi:10.4103/0971-4065.125051
  7. SAWEIRS W. W. M., GODDARD J.. What are the best treatments for early chronic kidney disease?: A Background Paper prepared for the UK Consensus Conference on Early Chronic Kidney Disease. Nephrology Dialysis Transplantation [online] 2007 September, 22(Supplement 9):ix31-ix38 [viewed 29 August 2014] Available from: doi:10.1093/ndt/gfm447
  8. GOTFRIED J., WIESEN J., RAINA R., NALLY J. V.. Finding the cause of acute kidney injury: Which index of fractional excretion is better?. Cleveland Clinic Journal of Medicine [online] December, 79(2):121-126 [viewed 29 August 2014] Available from: doi:10.3949/ccjm.79a.11030
  9. VALLONE GIANFRANCO, NAPOLITANO GIUSEPPINA, FONIO PAOLO, ANTINOLFI GABRIELE, ROMEO ANTONIO, MACARINI LUCA, GENOVESE EUGENIO, BRUNESE LUCA. US detection of renal and ureteral calculi in patients with suspected renal colic. Array [online] 2013 December [viewed 29 August 2014] Available from: doi:10.1186/2036-7902-5-S1-S3

Investigations - Fitness for Management

Fact Explanation
Full blood count Patients with chronic kidney disease can have anemia and thrombocytopenia which should be corrected. [1]
Arterial blood gas analysis Arterial blood gas analysis if there is any suspicion of metabolic acidosis. [1]
Serum electrolytes Impaired excretion of potassium can cause hyperkalemia, which if not corrected can induce ventricular fibrillation and cardiac arrhythmia. [1]
ECG ECG is helpful to identify the presence of cardiac arrhythmia. [1]
References
  1. MODI MP, VORA KS, PARIKH GP, SHAH VR, MISRA VV, JASANI AF. Anesthetic management in parturients with chronic kidney disease undergoing elective Caesarean delivery: Our experience of nine cases Indian J Nephrol [online] 2014, 24(1):20-23 [viewed 29 August 2014] Available from: doi:10.4103/0971-4065.125051

Management - General Measures

Fact Explanation
Health education Patients with already diagnosed chronic kidney disease should be educated about the risk of subfertility and pregnancy related complications like, hypertension, intrauterine growth retardation and premature labor. Patients who are planning pregnancy should seek medical advise first and preferably they should be followed up in a tertiary care unit.
Management of hyperemesis gravidarum Patients with hyperemesis gravidarum should be rehydrated with intravenous normal saline. Lost electrolytes (especially potassium) should also be supplied. Antiemetics will provide a symptomatic relief. [1]
Antihypertensives Treatment of high blood pressure is important in patient management, especially in the presence of renal disease. Since most of the commonly used antihypertensives are contraindicated during pregnancy, methyldopa, nifedipine and labetalol should be used in the treatment. [2]
Management of anemia Anemia in pregnancy is treated with supplementation of iron either orally or intravenously. Subcutaneous erythropoietin is also used for the treatment. In severe anemia occurring during the latter parts of the pregnancy may need blood transfusion. [3,4]
References
  1. KUSCU N, KOYUNCU F. Hyperemesis gravidarum: current concepts and management Postgrad Med J [online] 2002 Feb, 78(916):76-79 [viewed 29 August 2014] Available from: doi:10.1136/pmj.78.916.76
  2. MATHIESEN ER, RINGHOLM L, FELDT-RASMUSSEN B, CLAUSEN P, DAMM P. Obstetric nephrology: pregnancy in women with diabetic nephropathy--the role of antihypertensive treatment. Clin J Am Soc Nephrol [online] 2012 Dec, 7(12):2081-8 [viewed 29 August 2014] Available from: doi:10.2215/CJN.00920112
  3. MEHDI U., TOTO R. D.. Anemia, Diabetes, and Chronic Kidney Disease. Diabetes Care [online] December, 32(7):1320-1326 [viewed 29 August 2014] Available from: doi:10.2337/dc08-0779
  4. ZHU A, KANESHIRO M, KAUNITZ JD. Evaluation and Treatment of Iron Deficiency Anemia: A Gastroenterological Perspective Dig Dis Sci [online] 2010 Mar, 55(3):548-559 [viewed 29 August 2014] Available from: doi:10.1007/s10620-009-1108-6

Management - Specific Treatments

Fact Explanation
Hemodialysis In the presence of deranged renal functions hemodialysis is indicated.
Treatment of asymptomatic bacteriuria Asymptomatic bacteriuria should be treated with ciprofloxacin, ceftriaxone or augmentin as this is associated with risk of pyelonephritis. [1]
Treatment of UTI and pyelonephritis Amoxicillin-clavulanate combination and cephalosporins are commonly used in the treatment of UTI in pregnancy. Pyelonephritis may require intravenous antibiotics. [2]
Management of urolithiasis Patients with no immediate threat to the contralateral kidney (no evidence of renal failure or gross hydronephrosis) can be managed conservatively with analgesics. If not responding insertion of a JJ stent, placing a percutaneous nephrostomy tube or performing ureteroscopy may be useful. [3]
References
  1. IMADE PE, IZEKOR PE, EGHAFONA NO, ENABULELE OI, OPHORI E. Asymptomatic bacteriuria among pregnant women N Am J Med Sci [online] 2010 Jun, 2(6):263-266 [viewed 29 August 2014] Available from: doi:10.4297/najms.2010.2263
  2. ARTERO A, ALBEROLA J, EIROS JM, NOGUEIRA JM, CANO A. Pyelonephritis in pregnancy. How adequate is empirical treatment? Rev Esp Quimioter [online] 2013 Mar, 26(1):30-3 [viewed 29 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23546459
  3. GEORGESCU D, MULţESCU R, GEAVLETE B, GEAVLETE P, CHIUţU L. Ureteroscopy -- first-line treatment alternative in ureteral calculi during pregnancy? Chirurgia (Bucur) [online] 2014 Mar-Apr, 109(2):229-32 [viewed 29 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24742417