الفهرس 
Renal structural & physiological changes in normal pregnancyOnly 14 pages are availabe for public view
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Abstract
The kidneys undergo pronounced haemodynamic, renal tubular, and endocrine changes during pregnancy. During healthy pregnancy the kidney increases production of erythropoietin, active vitamin D, and rennin. Women with chronic kidney disease are less able to make the renal adaptations needed for a healthy pregnancy.
In 2002, the Kidney Disease Outcomes Quality Initiative (KDOQI) published a new chronic kidney disease (CKD) classification based on five categories of estimated glomerular filtration rate (eGFR). Before 2002, renal insufficiency is classified as mild, moderate, or severe according to serum creatinine values from 1,4 to 3,5 mg/dL and serum creatinine only had been used as cut-off .
The exact incidence of chronic renal disease could not be ascertained in pregnancy . There are several possible reasons for why chronic renal insufficiency is uncommonly associated with pregnancy. First and foremost is the fact that many women with significant renal insufficiency or renal failure are either beyond childbearing age or infertile. Another important reason may be incomplete reporting or data collection. Finally, the incidence of mild renal disease is often not included in many of the reported series.
Diagnosis of the cause of renal disease during pregnancy can be conducted with serologic,functional, and ultrasonographic testing . Renal biopsy is rarely performed during gestation. Proteinuria commonly reflects the degree of kidney damage but also holds prognostic value for progression of kidney disease.
Fertility is diminished in women with chronic kidney disease (CKD), especially in those with serum creatinine >3.0 mg/dL or who are dialysis dependent. CKD leads to impairment in the hypothalamic–pituitary–gonadal axis, causing decreased fertility.
If patients with CKD (regardless of underlying etiology) become pregnant, they are at increased risk for adverse maternal and fetal outcomes. This risk depends on the severity of baseline renal dysfunction, presence of uncontrolled hypertension, and degree of proteinuria.Women with preexisting mild CKD (stages 1-2), normal blood pressure, and no proteinuria generally have good maternal and fetal outcomes. Patients with moderate (stages3-4) or severe (stage 5) CKD have significantly increased risk of developing worsening renal function, proteinuria, hypertension, as well as increased rates of fetal complications.
The combined presence of GFR <40 mL/min/1.73 m2 (CKD stage 3) and proteinuria >1 g/d before conception predicted faster GFR loss after delivery, shorter time to dialysis, and low birth weight.
Management of chronic renal disease during pregnancy is best accomplished with a multidisciplinary team of specialists. Preconception counseling permits the explanation of risks involved with pregnancy.
The number of successful pregnancies in dialysis patients has improved over the years . The outcome is better in patients who conceived before starting dialysis compared with those who became pregnant while on dialysis. Since the 1980s, the infant survival rate has improved from 20–30% up to 50% in 2003.115 pregnancies reported by the EDTA, 46 were electively terminated. Of the remaining 69 pregnancies, only 16 (23%) resulted in surviving infants. Souqiyyeh, et al 1992 reported that 30% of pregnancies in their study resulted in live births. Thirty-six percent of the 320 pregnancies reported to the American Registry resulted in surviving infants.
The dialysis dose is an important consideration in pregnant patients because intensive dialysis results in a prolonged period of gestation, improved infant survival, and fewer maternal complications. A cumulative weekly dialysis dose exceeding 20 hours per week is recommended. Appropriate modifications include a high potassium, low calcium, and low bicarbonate dialysis bath. Daily dialysis treatments (5–6 days/week) will also allow gentle ultrafiltration and avoid rapid hemodynamic changes during the treatment.Dailyzer should be biochompatable &non-reuse and small surface area to rduce ultrafiltration rate during treatment.
As regard Pregnancy after Renal Transplant: Return of fertility is the rule in female transplant patients of childbearing age, occurring as early as 1 month following renal transplantation.Patients are advised to wait for at least 1 year and preferably 2 years following renal transplantation before conception.The pregnancy should be planned and the patient should discuss with treating nephrologist prior to conception.Renal function should be stable with serum creatinine <1.5 mg/dL.Proteinuria should be <500 mg/d.Blood pressure should be controlled with minimal number of medications.There should be no recent episodes of rejection or other transplant-related complications.
Preexisting kidney disease is an independent risk factor for preeclampsia, prematurity, low birth weight, and neonatal death .In the transplant setting, the impact of kidney disease on these outcomes is influenced by the degree of renal dysfunction, preexisting hypertension, and the extent of proteinuria.
Most deliveries occur early because of maternal and/or fetal compromise, rather than spontaneous preterm labor . Transplant recipients are at high risk for premature rupture of membranes, which also contributes to the increased risk for preterm labor, as does pyelonephritis and acute allograft rejection .