Renal Disorders Complicating Pregnancy

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Renal Disorders Complicating Pregnancy — Infection, Injury & Chronic Kidney Disease

Renal disorders range from urinary tract infection to acute kidney injury, chronic kidney disease, glomerular disease, dialysis, and transplant. This guide covers normal changes, infection, stones, acute and chronic disease, drug safety, delivery, and follow-up, using the KIDNEYS approach.

🎯 AT A GLANCE — KIDNEYS AND PREGNANCY

Pregnancy changes normal kidney function, so the usual adult limits do not apply — a serum creatinine of 0.9 mg/dL may signal significant disease

Urinary tract infection (UTI) is the commonest renal problem; untreated asymptomatic bacteriuria leads to pyelonephritis in about 30% and to preterm birth

Acute kidney injury (AKI) is still frequent in India, mainly from septic abortion, haemorrhage, pre-eclampsia, and sepsis

Chronic kidney disease (CKD) raises the risk of pre-eclampsia, preterm birth, growth restriction, and permanent loss of kidney function; the baseline creatinine and blood pressure predict the outcome

Pregnancy is a stress test for the kidney: plan before conception, share care between the obstetrician and the nephrologist, and never miss a UTI.

🚨 URGENT — ADMIT AND CALL THE NEPHROLOGIST

Pyelonephritis with fever, rigors, vomiting, sepsis, or no response in 48–72 hours — think of obstruction (a stone) or an abscess

Oliguria (under 400 mL/day), rising creatinine, or creatinine above 1.0 mg/dL in a woman without known kidney disease

Pulmonary oedema, severe hyperkalaemia, acidosis, or uraemic symptoms — plan urgent dialysis

Severe pre-eclampsia, HELLP syndrome (haemolysis, elevated liver enzymes, low platelets), or thrombotic microangiopathy

🗺️ THE PATHWAY AT A GLANCE

1 · ScreenUrine culture and dipstick at the first visit; BP and creatinine if known renal disease

2 · ClassifyInfection, stone, acute injury, chronic disease, glomerular disease, dialysis, or transplant

3 · Review drugsStop ACE inhibitors, ARBs, mycophenolate; start aspirin and calcium as indicated

4 · MonitorCreatinine, urine protein ratio, BP, urine culture; growth scans from 24–28 weeks

5 · TreatAntibiotics, BP control, thromboprophylaxis, dialysis by indication

6 · Deliver and followTimed delivery, then nephrology review and contraception counselling

STEP 1 · KNOW THE NORMAL — how pregnancy changes the kidney

🔬 PHYSIOLOGICAL CHANGES AND TEST LIMITS

Parameter	Normal pregnancy	Why it matters
Glomerular filtration rate (GFR)	Rises by 40–50% from the 6th week; peaks at about 12–16 weeks	Creatinine falls: normal is about 0.4–0.8 mg/dL
Serum creatinine	Above 0.8–0.9 mg/dL (72–80 µmol/L) is abnormal	Do not accept 'normal for an adult'; urea falls to about 9–12 mg/dL
Urine protein	Up to 300 mg/day (spot protein:creatinine ratio under 0.3)	Ratio above 0.3 needs evaluation; above 3.5 g/day is nephrotic
Collecting system	Dilated (hydronephrosis), right more than left, from progesterone and uterine pressure	Not obstruction by itself; symptoms or infection raise concern
Acid–base	Bicarbonate 18–22 mEq/L (respiratory alkalosis with compensation)	A bicarbonate below 18 suggests acidosis
Glycosuria	Common (reduced tubular reabsorption)	Does not diagnose diabetes

Use pregnancy ranges. Cystatin C and eGFR formulae are not reliable in pregnancy; measure creatinine and proteinuria directly.

STEP 2 · INFECTIONS — bacteriuria, cystitis and pyelonephritis

🦠 URINARY TRACT INFECTION IN PREGNANCY

Condition	Diagnosis	Treatment
Asymptomatic bacteriuria (2–10% of women)	Urine culture at the first visit: ≥ 10⁵ CFU/mL (colony-forming units) of one organism, no symptoms	Treat always: 4–7 days by culture; repeat culture 1–2 weeks after (test of cure); screen again later in pregnancy if high risk
Acute cystitis	Dysuria, frequency, urgency, suprapubic pain, no fever; culture and sensitivity	Oral antibiotic for 5–7 days by sensitivity; repeat culture after treatment
Acute pyelonephritis	Fever above 38 °C, flank pain, vomiting, costovertebral tenderness; pyuria; blood and urine cultures	Admit; IV fluids; IV ceftriaxone 1–2 g daily (or cefazolin, or an aminoglycoside); change to oral after 24–48 hours afebrile; total 10–14 days
Recurrent UTI	Two or more episodes in pregnancy	Prophylaxis after treatment: nitrofurantoin 50–100 mg or cefalexin 250–500 mg at night until delivery, plus post-coital advice

Complications of pyelonephritis: sepsis, acute respiratory distress syndrome (2–8%), anaemia, preterm labour, and AKI; monitor oxygen saturation and urine output; avoid beta-agonist tocolytics (risk of pulmonary oedema) and give IV fluids carefully.

💊 ANTIBIOTIC CHOICES — SAFE AND UNSAFE

Antibiotic	Use in pregnancy
Cephalosporins (cefalexin, cefixime, ceftriaxone), amoxicillin-clavulanate	Safe and commonly used by sensitivity
Nitrofurantoin	Acceptable in the second trimester; avoid in the first trimester if alternatives exist and near term (haemolysis in G6PD deficiency); not for pyelonephritis
Fosfomycin 3 g single dose	Option for cystitis or bacteriuria where available
Trimethoprim and co-trimoxazole	Avoid in the first trimester (folate antagonism) and near term; use only if no alternative
Fluoroquinolones, tetracyclines	Avoid in pregnancy
Aminoglycosides	Use with levels and kidney monitoring only when necessary

Follow the local antibiogram. Resistance in Indian E. coli, including extended-spectrum beta-lactamase (ESBL) producers, is common — always send a culture and check the national antimicrobial guidance.

STEP 3 · STONES AND ACUTE INJURY — obstruction and AKI

🪨 UROLITHIASIS (KIDNEY STONES)

Flank pain, haematuria, or infection; stones occur in about 1 in 1,500–3,000 pregnancies; hydronephrosis is normal, so look for a stone (or an absent ureteric jet)

First-line imaging: ultrasound; magnetic resonance urography or low-dose CT if unclear

Most stones pass (about 70%) with fluids, analgesia (paracetamol, opioids), and antiemetics; avoid NSAIDs late in pregnancy

Infected obstructed system is an emergency: ureteric stent or percutaneous nephrostomy with antibiotics; ureteroscopy for persistent stones

Shock-wave lithotripsy is contraindicated in pregnancy

⚡ ACUTE KIDNEY INJURY (AKI)

Cause	Examples	Management
Pre-renal	Hyperemesis, haemorrhage (APH, PPH), sepsis, dehydration	Restore volume, correct blood loss, treat the cause
Intrinsic	Acute tubular necrosis, severe pre-eclampsia or HELLP, septic abortion, acute fatty liver of pregnancy, bilateral cortical necrosis	Deliver if it is pre-eclampsia or fatty liver; antibiotics and source control for sepsis
Thrombotic microangiopathy	TTP, atypical HUS (thrombotic thrombocytopenic purpura; haemolytic uraemic syndrome): haemolysis, low platelets, renal failure	Plasma exchange or eculizumab with a specialist; ADAMTS13 level
Post-renal	Stone, ureteric injury, or pressure from a gravid uterus	Ultrasound; stent or nephrostomy
Dialysis indications	Urea above 100 mg/dL (some use lower thresholds), creatinine rising, hyperkalaemia, acidosis, fluid overload	Start early and aim for pre-dialysis urea below 50 mg/dL

Drugs to avoid in AKI: NSAIDs, ACE inhibitors, ARBs, aminoglycosides unless necessary, and contrast media unless essential; dose-adjust all drugs to the GFR.

STEP 4 · CHRONIC DISEASE — CKD, glomerular disease, dialysis and transplant

🩺 CHRONIC KIDNEY DISEASE (CKD) IN PREGNANCY

Baseline (before pregnancy)	Risks	Approach
Mild: creatinine below 1.4 mg/dL (eGFR above 60)	Mostly good outcomes (live birth above 95%); pre-eclampsia 20–30%; small risk of GFR loss	Monthly review; BP target about 130/80 (some use under 140/90); aspirin
Moderate: creatinine 1.4–2.4 mg/dL (eGFR 30–60)	Preterm birth and growth restriction 40–60%; pre-eclampsia up to 60%; 40% lose GFR permanently	Joint renal–obstetric clinic every 2–4 weeks; anaemia, acidosis, and BP care
Severe: creatinine above 2.4 mg/dL (eGFR below 30)	Live birth about 50–60%; most deliver preterm; about 50% reach end-stage kidney disease	Counsel against pregnancy or weekly care; consider dialysis if urea high

Topic	Advice
Before conception	Stable disease, BP below 140/90, proteinuria under 1 g/day; stop ACE inhibitors, ARBs, statins; folic acid 5 mg
Antihypertensives	Labetalol, nifedipine, or methyldopa; avoid ACE inhibitors, ARBs, spironolactone
Aspirin and calcium	Low-dose aspirin (75–150 mg nightly from 12 weeks); calcium 1–1.5 g/day where intake is low
Anaemia	Iron; erythropoietin if haemoglobin stays low; target 10–11 g/dL
Monitoring	Creatinine, urine protein ratio, urea, electrolytes, urine culture every 4 weeks; growth scans from 24–28 weeks

🧪 GLOMERULAR DISEASE, LUPUS NEPHRITIS AND OTHER CONDITIONS

Condition	Key points
Nephrotic syndrome (proteinuria above 3.5 g/day, low albumin, oedema)	High risk of thrombosis: prophylactic heparin if albumin is below 2.0–2.5 g/dL; careful diuretics; avoid statins; treat the cause (steroids for minimal change)
IgA nephropathy and other glomerulonephritis	Outcome depends on baseline GFR, BP, and proteinuria; flare can mimic pre-eclampsia; biopsy before 28 weeks only if rapid deterioration
Lupus nephritis	Disease quiet for at least 6 months; continue hydroxychloroquine; azathioprine, prednisolone, tacrolimus allowed; stop mycophenolate (6 weeks before conception), cyclophosphamide, and ACE inhibitors; aspirin
Diabetic nephropathy	Tight glucose; high pre-eclampsia and preterm risk; aspirin; retinal and BP review
Polycystic kidney disease, reflux nephropathy, solitary kidney	Hypertension and UTI risk; screen urine cultures; solitary kidney with normal GFR does well; donors have a small excess of pre-eclampsia

Pre-eclampsia versus a renal flare: in a flare, active urinary sediment (red cells and casts), low complement, rising anti-dsDNA, and early onset (before 20 weeks) are common; in pre-eclampsia, sFlt-1:PlGF ratio is high and platelets, liver enzymes, and uric acid change.

🔁 DIALYSIS AND KIDNEY TRANSPLANT

Group	What to do
Women on dialysis	Fertility is low; if pregnant, intensify dialysis (more than 20 hours/week, ideally nocturnal or daily); pre-dialysis urea below 50 mg/dL; avoid hypotension; live birth about 70–80% but preterm
Transplant recipients	Wait 1–2 years after transplant with stable graft (creatinine below 1.5 mg/dL, proteinuria under 500 mg/day, no recent rejection); live birth above 90%; preterm birth and pre-eclampsia common
Drugs after transplant	Prednisolone, azathioprine, tacrolimus (monitor levels) are safe; stop mycophenolate, sirolimus, and everolimus before conception; cyclosporine acceptable
Delivery	Mode by obstetric indication; transplant kidney sits in the pelvis but rarely blocks labour; give steroid cover and prophylactic antibiotics
Breastfeeding	Safe with prednisolone, azathioprine, and tacrolimus

STEP 5 · DELIVER AND FOLLOW UP — timing, labour, and after

🏥 DELIVERY AND AFTERWARDS

Topic	Advice
Fetal surveillance	Anomaly scan; growth scans every 3–4 weeks from 24–28 weeks; uterine artery Doppler; amniotic fluid; kick counts
Timing of delivery	Stable CKD: up to 37–40 weeks; deteriorating function, severe pre-eclampsia, or fetal compromise: earlier; deliver in a unit with a neonatal intensive care unit
Mode	Vaginal birth preferred; caesarean for obstetric indications; fluid balance and urine output are closely monitored
After delivery	Creatinine and BP checks; avoid NSAIDs; GFR may fall in the first 6 months; nephrology review at 6 weeks
Contraception	Progestogen-only methods or intrauterine devices are preferred; avoid oestrogen if hypertensive, nephrotic, or with active lupus
Long-term	Lifelong follow-up: BP, proteinuria, and kidney function; pre-eclampsia and AKI raise the later risk of CKD

⚠️ COMMON PITFALLS

Accepting a 'normal' adult creatinine (such as 1.0 mg/dL) as normal in pregnancy

Not sending a urine culture, or stopping antibiotics early without a test of cure

Using ACE inhibitors, ARBs, NSAIDs, or mycophenolate in a woman who may conceive

Missing thrombosis risk in nephrotic syndrome, or missing AKI after haemorrhage or sepsis

Treating a lupus or glomerulonephritis flare as pre-eclampsia — or the reverse

Memory Aid

KIDNEYS

Seven points for renal disease in pregnancy.

K

Know the physiology — GFR up, creatinine down, proteinuria up to 300 mg/day

I

Infection — culture at the first visit; treat bacteriuria; admit pyelonephritis

D

Drugs — stop ACE inhibitors, ARBs, mycophenolate; avoid NSAIDs

N

Nephrotic syndrome — think of thrombosis; give heparin when albumin is low

E

Evaluate pre-eclampsia versus a renal flare

Y

Your team — obstetrician and nephrologist together, with a neonatal unit

S

Surveillance — creatinine, urine protein, BP, urine culture, and growth scans

Remember: use pregnancy ranges, treat infection fully, protect the kidney from harmful drugs, and plan before conception and after delivery.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary based on the American College of Obstetricians and Gynecologists (ACOG), the Royal College of Obstetricians and Gynaecologists (RCOG), KDIGO (Kidney Disease: Improving Global Outcomes), the UK Kidney Association, and standard obstetric nephrology texts; written from memory, not from a Government of India renal protocol; thresholds, intervals and regimens vary between guidelines — follow local protocol, obtain consent, and involve a senior obstetrician in any high-risk case.