1. Mamdouh Albaqumi, MD, FASN Nephrology Section Department of Medicine King Faisal Specialist Hospital Hypertension and CKD in the Pregnancy

2. How many pregnant patients with CKD did you treat? A More than 4 B 2 to 4 C 1 to 2 D None

3. How many pregnant patients with CKD did you treat? 1.More than 4 2.2 to 4 3.1 to 2 4.None

4. How many pregnant patients on Dialysis did you treat? A More than 4 B 2 to 4 C 1 to 2 D None

5. How many pregnant patients on Dialysis did you treat? 1.More than 4 2.2 to 4 3.1 to 2 4.None

6. Case Presentation  She was diagnosed with vesicouretheral reflux at age 8,  Renal function was normal.  UA: trace protein, 0 RBC  Renal US increased echogenicity.  Nuclear scan: 23% function of R kidney. History: Chief complain: Patient is 29 years old Female who presented to ER at 18 weeks gestation with uncontrolled hypertension and Cr 370 umol/L

7. Case Presentation  Lost follow up for years  Had 2 pregnancies, 2000, 2006 both resulted in still birth in her second trimester  In 2006: Cr 151- 195 umol/L, UA : +1 Protein, 0 RBC History: Chief complain: Patient is 29 years old Female who presented to ER at 18 weeks gestation with uncontrolled hypertension and Cr 370 umol/L

8. Labs:  Liver function Test, LDH, Uric acid normal  Platelets 370 Hgb 84  Lupus screen, Complements, Anti phospholipids: normal  UA+1 protein, 0 RBC, 24 hour collection: 980mg protein/24h  Uterine US: 19 weeks Fetus  Renal US: bilateral echogenic kidneys On admission:  BP 180/110  No edema Case Presentation UreaCreat.KHCO3GFR 30 mmol/L370 umol/L4.3 mmol/L16 mmol/L14 ml/min

9. B With the current lab data, How would you treat the patient next? A Emergent C-Section C Control the blood pressure, correct the anemia, and monitor closely. Dialysis

10. With the current lab data, How would you treat the patient next? 1.Emergent C-Section 2.Dialysis 3.Control the blood pressure, correct the anemia, and monitor closely.

11. What are the indication for initiating dialysis in moderate to severe CKD (other than uremia and metabolic abnormalities)? A Uncontrolled hypertension B Urea more than 30 umol/L C No maternal indication, but you must start dialysis to improve fetal outcome. D No strong evidence to start dialysis

12. What are the indication for initiating dialysis in moderate to severe CKD (other than uremia and metabolic abnormalities)? 1.Uncontrolled hypertension 2.Urea more than 30 umol/L 3.DNo maternal indication, but you must start dialysis to improve fetal outcome. 4.No strong evidence to start dialysis

13. Registry Of Pregnancy In Dialysis Patients Therapeutic Abortion Still Pregnant Surviving Infants Neonatal Deaths Stillbirths Spontaneous Abortion 1st Trimester Spontaneous Abortion 2nd Trimester Okundaye et al. AJKD, Vol 31, No 5 (May), 1998: pp 766-773

14. Registry Of Pregnancy In Dialysis Patients Therapeutic Abortion Still Pregnant Surviving Infants Neonatal Deaths Stillbirths Spontaneous Abortion 1st Trimester Spontaneous Abortion 2nd Trimester Okundaye et al. AJKD, Vol 31, No 5 (May), 1998: pp 766-773 Still Pregnant Surviving Infants Spontaneous Abortion 2nd Trimester Spontaneous Abortion 1st Trimester Stillbirths Neonatal Deaths Conceived after starting dialysis n=184 Conceived prior to dialysis n=57

15. Pregnancy in Moderate to Severe CKD Jones et al. NEJM. 1996. July. 226-234 Surviving Infants Neonatal Deaths & Stillbirths >40 % preterm delivery, >10%fetal distress CKD Still Pregnant Therapeutic Abortion Surviving Infants Neonatal Deaths Stillbirths Spontaneous Abortion 1st Trimester Spontaneous Abortion 2nd Trimester ESRD

16. Degree of renal failureProposed Management ESRD on dialysisIntensify treatment GFR less than 10ml/mingets pregnant start dialysis GFR 10- 30 ml/min ??????

17. C What is the optimal blood pressure target in this patient? A Less than 140/90 B Less than 120/80 MAP target of 70 to ensure placental perfusion D No evidence to support a target BP

18. What is the optimal blood pressure target in this patient? 1.Less than 140/90 2.Less than 120/80 3.MAP target of 70 to ensure placental perfusion 4.No evidence to support a target BP

19. The Control of Hypertension In Pregnancy Study CHIPS Magee at al. BJOG. 2007 Jun;114(6):770 N =132 women Less tight BP control DBP 100 Tight BP control DBP 85 serious maternal complications 3.1%4.6% preterm birth36.4%40.0% birth weight2675 +/- 858g2501 +/- 855 g neonatal intensive care unit (NICU) admission 22.7%34.4% serious perinatal complications 13.6%21.5%

20. C Can we start CAPD in this patient? A Yes, PD can safely be initiated B PD can be initiated only if HD is unsuccessful No, HD is the only safe dialysis modality

21. Can we start CAPD in this patient? 1.Yes, PD can safely be initiated 2.PD can be initiated only if HD is unsuccessful 3.No, HD is the only safe dialysis modality

22. Registry Of Pregnancy In Dialysis Patients Therapeutic Abortion Surviving Infants Neonatal Deaths Stillbirths Spontaneous Abortion 1st Trimester Spontaneous Abortion 2nd Trimester Okundaye et al. AJKD, Vol 31, No 5 (May), 1998: pp 766-773 Still Pregnant Surviving Infants Spontaneous Abortion 1st Trimester Stillbirths Neonatal Deaths Spontaneous Abortion 1st Trimester Therapeutic Abortion Peritoneal Dialysis n=35 Hemodialysis n=149

23.  BP was controlled with methyldopa, labetolol, hydralazine 140-120/90-80  Urea: 30 to 21mmol/L within 1 week  Creatinine: 370 to 312 umol/L  At week 24: controlled BP, Urea 16mmol/L Cr 310umol/L Follow UP

24. Thank You