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Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal.

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Presentation on theme: "Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal."— Presentation transcript:

1 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Pre-eclampsia “A common human-specific disease of pregnancy characterised by novel and progressive hypertension and proteinuria after 20 weeks gestation.”

2 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Clinical features Hypertension Proteinuria Fetal growth restriction Abdominal pain Headaches Visual scotoma Deranged LFTs Thrombocytopenia Haemolysis DIC Hyperreflexia Seizures Renal failure Death εκ-λαμψια

3 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Demographic and clinical risk factors 1.Older mothers (>40 years, RR=2) 2.Primigravidae (RR=3) 3.Previous pre-eclampsia (RR=7) 4.Family history of pre-eclampsia (RR=3) 5.Obesity(BMI>35, RR=4) 6.New sexual partner 7.Diabetes mellitus(RR=4) 8.Chronic hypertension(40x higher prevalence in cases) 9.Chronic kidney disease 10.Thrombophilia 11.Connective tissue diseases(RR=6) 12.Multiple pregnancies(RR=3)

4 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Diagnosis No gold standard diagnostic test No (reliable) animal models Variable diagnostic criteria used

5 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Diagnosis International Society for the Study of Hypertension in Pregnancy (ISSHP, 2001) Research definition De novo hypertension (systolic blood pressure >140mmHg, diastolic blood pressure >90mmHg) after 20 weeks’ gestation plus proteinuria (greater than 300mg/d or protein:creatinine ratio >30mg/mmol). Clinical definition As above but “in the absence of proteinuria the disease is highly suspect when increased blood pressure is accompanied by: Headache Blurred vision Abdominal pain Low platelets Abnormal liver enzymes.”

6 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Epidemiology Incidence 2-8% of pregnancies –32,000 affected pregnancies/year in UK –6,500,000 affected pregnancies/year worldwide

7 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Epidemiology Directly led to the death of 18 mothers in the UK from Implicated in 135 stillbirths in the UK in 2006 Lewis.G editor. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer London: CEMACH; 2007 Acolet D editor. Confidential Enquiry into Maternal and Child Health (CEMACH) Perinatal Mortality 2006: England,Wales and Northern Ireland. London: CEMACH; 2008

8 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Epidemiology Directly implicated in 68,000 maternal deaths per year worldwide.

9 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Treatment of pre-eclampsia Deliver the fetus and placenta Serial monitoring of fetal growth Blood pressure control Clinical surveillance of impending eclampsia or HELLP Magnesium sulphate + betamethasone

10 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Prevention of pre-eclampsia What is the pathological process?

11 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Prevention of pre-eclampsia Genetic predisposition Immunological dysfunction Abnormal placentation Endothelial dysfunction Coagulation abnormalities Cardiovascular maladaptation Abnormal trophoblast invasion Decreased uteroplacental perfusion Disordered endothelin metabolism Cytokines and growth factors Cardiovascular or renal disease ADMA / nitric oxide imbalance Imbalanced prostaglandin metabolism Relaxin/ metalloprotease-2 deficiency Anti-AT2 IgG Anti-cardiolipin IgG and IgM Anti-spermatazoa antibodies STOX-1 mutation ACE polymorphisms NOS polymorphisms TNF-α IL-6 IL-1α Fas ligand VEGFPlGF s-Flt-1 Endoglin COMT deficiency

12 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Prevention of pre-eclampsia Diuretics Progesterone Vitamin C and E GTN Calcium supplements Garlic Aspirin L -arginine Vitamin B6

13 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Prevention of pre-eclampsia Calcium supplements Systematic review women All women 52% relative risk reduction High risk women 78% relative risk reduction Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database Syst.Rev Jul 19;3:CD Dietary calcium is adequate in most patients. Supplementation only recommended with dietary insufficiency Hofmeyr GJ, Duley L, Atallah A. Dietary calcium supplementation for prevention of pre-eclampsia and related problems: a systematic review and commentary. BJOG 2007 Aug;114(8):

14 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Prevention of pre-eclampsia Aspirin Systematic review women All women 17% relative risk reduction High risk women 25% relative risk reduction NNT = 72NNT = 19 Duley L, Henderson-Smart DJ, Meher S, King JF. Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst.Rev Apr 18;(2)(2):CD Preterm delivery RRR 8% Perinatal death RRR 14% SGA RRR 10%

15 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Prevention of pre-eclampsia

16 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 The kidney in pre-eclampsia Hypertension Increased risk of ESRD AKI Proteinuria

17 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011

18 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011

19 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011

20 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011

21 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011

22 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Pre-eclampsia and the kidney Glomerular endotheliosis Capillary endothelial oedemaVasospasmMicrothrombi Light microscopy normal by 40 days post-partum GBM thickening can persist on EM

23 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Pre-eclampsia and AKI Intraglomerular thrombosis Systemic vasoconstriction Intravascular fluid depletion Endothelial dysfunction Antihypertensive medication Loss of autoregulation Haemorrhage DIC Placental abruption Emergency Caesarean AKI Affects 1-2%

24 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Pre-eclampsia – renal treatment Keep them dry Dialyse when needed Wait for it all to go away Encourage baby extraction

25 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Anaesthetists Being unlucky Patients die from fluid overload Patients don’t die from kidney failure

26 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 What’s new in pre-eclampsia? Angiogenic factors Podocyturia Predicting pre-eclampsia Biomarkers Laboratory Imaging

27 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Angiogenic factors and pre-eclampsia Gene expression profiling of placental tissue from women with and without pre- eclampsia (PE) 1 Up-regulation of soluble fms-like tyrosine kinase-1 (s-Flt-1) 1 s-Flt-1 increased in serum in PE 2 s-Flt-1 increased in urine in PE 3 Binds to VEGF and Placental Growth Factor (PlGF) antagonising their function Serum PlGF decreased in PE 2 Urine PlGF decreased in PE 3 1 Maynard S, Min J-Y et al. J. Clin. Invest 2003;111:649 2 Levine RJ, Maynard SE et al. NEJM 2004;350:672 3 Buhimsci CS, Magloire L et al. Obstet Gynecol 2006;107:1103

28 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 sVEGF-R 1 sFlt-1 sVEGF-R 1 sFlt-1 VEGF VEGF-R 1 Flt-1 VEGF-R 2 Flk-1 VEGF-R 2 sVEGF-R 1 sFlt-1 Survival, migration and differentiation of endothelial cells Tyrosine kinase No signal VEGF PlGF Activation of VEGF-R 2 by transphosphorylation Displacement of VEGF from inactive receptors Destabilise inactive VEGF-R heterodimers Endothelial cell VEGF-R 1 Placenta Normal pregnancy Pre-eclampsia Angiogenesis Anti-angiogenesis

29 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Other supportive evidence s-Flt-1 Hypertension Proteinuria

30 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Other supportive evidence Hypertension Proteinuria

31 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Other supportive evidence …in humans?

32 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011

33 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Romero R, Nien JK, Espinoza J, Todem D, Fu W, Chung H, et al. A longitudinal study of angiogenic (placental growth factor) and anti-angiogenic (soluble endoglin and soluble vascular endothelial growth factor receptor-1) factors in normal pregnancy and patients destined to develop preeclampsia and deliver a small for gestational age neonate. J.Matern.Fetal.Neonatal Med Jan;21(1):9-23.

34 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Diagnosis of pre-eclampsia will change International Society for the Study of Hypertension in Pregnancy (ISSHP, 2001) Research definition De novo hypertension (systolic blood pressure >140mmHg, diastolic blood pressure >90mmHg) after 20 weeks’ gestation plus proteinuria (greater than 300mg/d or protein:creatinine ratio >30mg/mmol). Clinical definition As above but “in the absence of proteinuria the disease is highly suspect when increased blood pressure is accompanied by: Headache Blurred vision Abdominal pain Low platelets Abnormal liver enzymes.” Elevated serum sFlt1:PlGF ratio Elevated urine sFlt1:PlGF ratio Elevated serum endoglin Presence of podocyturia or podocyte-specific mRNA

35 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Predicting pre-eclampsia Pre-eclampsia affects 5% of pregnancies 50% of patients with pre-eclampsia have no risk factors 90% of patients with risk factors do not develop pre-eclampsia

36 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Current clinical practice Demographic and clinical risk factors Frequent monitoring Aspirin Uterine artery doppler (20-24 weeks) High risk – 14.4% No uterine artery notch – 9.2% Uterine artery notch – 30% Conde-Agudelo A, Villar J, Lindheimer M. World Health Organization Systematic Review of Screening Tests for Preeclampsia. Obs. Gynecol. 2004;104(6),

37 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Predicting pre-eclampsia Conde-Agudelo A, Villar J, Lindheimer M. World Health Organization Systematic Review of Screening Tests for Preeclampsia. Obs. Gynecol. 2004;104(6), Uterine artery doppler Human chorionic gonadotrophin Alpha-fetoprotein Inhibin A Pregnancy-associated plasma protein A Corticotrophin releasing hormone Oestriol Urinary calcium excretion Activin A Microtransferrinuria Urine kallikrein Homocysteine N-acetyl-β-glucosaminidase Fibronectin Antiphospholipid antibodies “As of 2004, there is no clinically useful screening test to predict the development of pre-eclampsia.”

38 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Combining biomarkers Giguère Y, Charland M, Bujold E et al. Combining biochemical and ultrasonographic markers in predicting preeclampsia: a systematic review. Clin Chem 2010;56(3): AFP > 2.5MoM + hCG > 2.5MoM + PI > 95% centile + bilateral uterine artery weeks Sensitivity 64% Specificity 97% PlGF + PAPP-A + PI + mean arterial pressure + “multiple maternal demographic weeks Sensitivity 93% Specificity 95%

39 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Combining biomarkers Giguère Y, Charland M, Bujold E et al. Combining biochemical and ultrasonographic markers in predicting preeclampsia: a systematic review. Clin Chem 2010;56(3): “Numerous papers have been published on potential biomarkers for identifying women predisposed to development of PE before the onset of clinical symptoms… …new tests that will contribute to better predictive performance characteristics of a PE-risk model need to be developed.”

40 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 A two stage pathological process weeks Impaired trophoblast invasion of myometrium Poor spiral artery adaptation Placental ischaemia Abnormal implantation Clinical manifestations of pre-eclampsia Generalised maternal endothelial dysfunction Systemic release of pro-inflammatory and antiangiogenic mediators HypertensionProteinuria

41 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Participants

42 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Outcomes

43 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Demographic and clinical details Total (n=102) Pregnancy complicated by pre- eclampsia (n=11) Normal pregnancy (n=91) p value Age at conception (years)28.8± ± ± Ethnicity White European Other 89 (86%) 14 (14%) 10 (91%) 1 (9%) 78 (86%) 13(15%) 0.06 Primigravida (n (%))26 (26%) 4 (36%)22 (24%)0.46 Past history of pre-eclampsia (n (%))35 (46%) 4 (57%)31 (45%)1.00 Family history of pre-eclampsia (n (%))15 (15%) 3 (27%)12 (13%)0.20 BMI at booking (kg/m 2 )30.8± ± ± Systolic blood pressure at booking (mmHg) 123±12124±13123± Diastolic blood pressure at booking (mmHg) 77±1179±977± Prescription of aspirin prophylaxis (n (%)) 15 (15%) 1 (9%)14 (15%)1.00 Participants No differences in demographic and clinical details at recruitment between normal and pre-eclamptic pregnancies

44 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 SELDI spectra Participant 1 Participant 2

45 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 ANN results ANN modelling selected a panel of 5 protein peaks 9080 Da 8020 Da 4648 Da 4813 Da Da Cross validation model results: Normal pregnancy correctly classified: 100% Pre-eclampsia correctly classified: 92% 793 peaks differentially expressed between normal pregnancy and pre-eclampsia

46 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 ANN results 9080 Da8020 Da4648 Da4813 Da11320 Da

47 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Sensitivity: 87% Specificity: 82% Model performance

48 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Summary 1.Pre-eclampsia is common 2.AKI from pre-eclampsia is rare and managed by timely delivery and supportive care 3.Pregnant patients with CKD should receive aspirin from 12 weeks to delivery 4.Improved knowledge re: pathophysiology may lead to new treatments to delay or prevent pre-eclampsia 5.Predictive tests for pre-eclampsia are on the horizon.

49 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case studies

50 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 23 year old G2 P0+1 Chronic pyelonephritis/reflux No recent infections 10 weeks pregnant

51 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 No medication BP 125/78 Urine dip: Prot +, Leu -, Nit – Urine P:CR 43 mg/mmol Serum creatinine: 138 µmol/l

52 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 Will pregnancy affect kidney disease? Will she have a successful pregnancy?

53 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Baseline renal function

54 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Blood pressure Neonatal death risk Diastolic BPAbsolute risk <700.9% % % >90 or treated15.3%

55 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 What to do?

56 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 Aspirin 75mg od from 12 weeks to delivery

57 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 20 weeks No symptoms Aspirin 75mg od BP 110/72 Creat 119 µmol/l Urine pro +, leu +, nit + P:CR 55 mg/mmol

58 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 MC+S Coliforms Sensitive to ciprofloxacin, trimethoprim, nitrofurantoin, cefalexin and co-amoxiclav Resistant to amoxicillin

59 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Drugs, CKD and pregnancy Antibiotics 1.Cephalosporins 2.Penicillins 3.Gentamicin 4.Erythromycin 1.Quinolones 2.Tetracyclines 1.Trimethoprim (in 1 st trimester) 2. Nitrofurantoin (in 3 rd trimester)

60 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 26 weeks gestation Aspirin 75mg od Dysuria x 2 days BP 131/81 Urine: Pro +, Bld ++, Leu +, Nit + MC+S: Coliforms again

61 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 What to do?

62 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Management of CKD and hypertension in pregnancy Urinary tract infection Asymptomatic bacteruria Pyelonephritis Non-pyelonephritic UTI In pregnancy Treat Asymptomatic bacteruria Pyelonephritis Non-pyelonephritic UTI Treat Second or more episode in pregnancy? Prophylaxis

63 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 33 weeks Well Aspirin 75mg od, cefalexin 125mg nocte BP 153/91 Creat 143 µmol/l P:CR 80 mg/mmol

64 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 Repeat BP 154/92, 166/88, 149/90

65 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 What to do?

66 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Management of CKD and hypertension in pregnancy Blood pressure control Chronic hypertension Target BP <150/100 Chronic hypertension + CKD Target BP <140/90 Do not treat to DBP<80mmHg Chronic hypertension + proteinuric CKD Target BP <140/90

67 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Drugs, CKD and pregnancy Antihypertensives 1.Labetalol 2.Methyldopa 3.Nifedipine 4.Hydralazine 1.ACE inhibitors 2.ARBs 3.Spironolactone 4.Aliskiren 5.Moxonidine 6.Minoxidil 7.Diltiazem

68 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 34 weeks Abdominal pain – RUQ Headache Aspirin 75mg od, cefalexin 125mg od, labetalol 200mg tds BP 173/105 PCR 205 mg/mmol Serum creatinine 192 µmol/l

69 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 What to do?

70 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 Admit to maternity unit Add nifedipine or methyldopa CTG FBC, LFTs, clotting Consider magnesium sulphate Plan for delivery

71 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2

72 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 Preconception counselling 35 year old. Nulliparous FSGS

73 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 Ramipril 10mg od Simvastatin 40mg od BP 118/64 Serum creatinine 84 µmol/l, eGFR 73 ml/min Urine PCR 342 mg/mmol Serum albumin 38g/l

74 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 1 Will pregnancy affect kidney disease? Will she have a successful pregnancy?

75 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Proteinuria? Imbasciati E et al. AJKD 2007;49:753

76 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Proteinuria p=0.60 p=0.86 p=0.03

77 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 What to do?

78 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 Stop statin Stop ACEi Advise to commence aspirin from 12 weeks Folic acid ?

79 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 6 months later Oedema x 2 months Cellulitis left leg BP 163/91 Urine PCR 854 mg/mmol Serum albumin 21 g/l Serum creatinine 114 µmol/l, eGFR 54ml/min

80 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 2 weeks later Acute dyspnoea, pleuritic chest pain, left flank pain, episode of haematuria.

81 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 BP 181/104 Serum creatinine 434 µmol/l US: Renal vein thrombosis V/Q: Extensive mismatch. High probability of PE. Heparin and warfarin commenced Amlodipine 5mg od

82 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 2 months later BP 144/85 Serum creatinine 312 µmol/l Urine PCR 443mg/mmol Serum albumin 24 g/l Transplant work-up and dialysis planning

83 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Case 2 A little pessimistic… …but a risk worth considering

84 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Quiz

85 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Quiz No conferring No Google My word is final

86 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 1 Which of the following statements about pregnancy and haemodialysis is incorrect? 1.Target weight increases by about 300g/week from the second trimester 2.At least 20 hours/week dialysis is recommended 3.ESA requirement increases by about 85% 4.Preterm labour is commonly caused by oligohydramnios 5.Antihypertensive treatment should be titrated to maintain blood pressure <140/90 mmHg

87 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 2 Approximately, how many pregnancies are there per year in the UK?

88 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 3 The risk of pre-eclampsia is increased with: 1.Aspirin 2.Calcium supplements 3.Cigarettes 4.Singleton pregnancies 5.First time pregnancies

89 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 4 Which of the following is safe to use in pregnancy? 1.Ciprofloxacin 2.Cyclophosphamide 3.Cyclosporine 4.Chlorambucil 5.Candesartan

90 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 5 A renal biopsy during pregnancy should be considered for which of the following: 1.De novo nephrotic syndrome at 37 weeks 2.Persistent invisible haematuria, urine PCR 55 mg/mmol and serum creatinine 99 µmol/l from booking 3.Severe de novo hypertension and proteinuria at 26 weeks 4.ANCA positive, oliguric AKI with blood and protein and a creatinine of 446 µmol/l at 33 weeks 5.BP 141/89, urine blood ++, protein ++, creat 131 µmol/l, ANA +ve, dsDNA +ve at 23 weeks

91 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 6 What is the chance of a woman with serum creatinine 200 µmol/l at conception needing dialysis within a year of pregnancy? 1.1 in in in in in 2

92 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 7 A woman on PD thinks she might be pregnant. Serum βHCG is equivalent to an 8 week old fetus. Ultrasound scanning does not show a fetal heart rate as expected. What advice should be given? 1.Molar pregnancy likely – requires hysteroscopy and curettage 2.Measure serum alfa-fetoprotein 3.Repeat serum βHCG and ultrasound in 1 – 2 weeks 4.Diagnosis of missed abortion – consolation 5.Explain βHCG is elevated in ESRD

93 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 8 A 32 year old with asthma, previous depression and diabetic nephropathy develops gestational hypertension. Which treatment is most appropriate? 1.Methyldopa 2.Valsartan 3.Bendroflumethiazide 4.Labetalol 5.Nifedipine

94 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 9 You are asked to see a 26 year old following her first pregnancy which ended in severe pre-eclampsia yesterday at 35 weeks. She is oliguric and creatinine has climbed from 121 to 158 µmol/l in 24 hours. CVP is 4 mmHg and BP 185/83 mmHg on labetalol 200mg bd. Renal ultrasound shows mild left hydronephrosis.

95 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 9 You are asked to see a 26 year old following her first pregnancy which ended in severe pre-eclampsia yesterday at 35 weeks. She is oliguric and creatinine has climbed from 121 to 158 µmol/l in 24 hours. CVP is 4 mmHg and BP 185/83 mmHg on labetalol 200mg bd. Renal ultrasound shows mild left hydronephrosis. What is the most appropriate management plan? 1.Ask how the baby is and repeat bloods in 6 hours 2. Oral magnesium glycerophosphate 2 tabs bd 3. Aspirin 75mg od 4. Nephrostomy left kidney 5. IV colloid 500ml stat followed by 0.9% sodium chloride – 1000ml/4 hours

96 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Question 10 How are babies made? 1.Nobody knows 2.When a mummy and a daddy love each other very much they give each other a special kiss 3.By a woman sitting on a seat warmed by a man’s bottom 4.Stork 5.By doing “the filthy thing”

97 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Congratulations You have survived.

98 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Courtesy of Matt Hall Nottingham Renal Unit February 2011 Slides available at


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