PENYAKIT GINJAL YANG

MENYERTAI KEHAMILAN,
PERSALINAN DAN NIFAS

Kuliah
Diploma III
Dr. IGN Agung Tresna E, M.Biomed, Sp.P.D.

DIVISI GINJAL DAN HIPERTENSI RSUP SANGLAH/FK UNUD

Normal Physiologic Alterations of Pregnancy
Normal Renal Alterations
in Pregnancy
Changes in GFR
• GFR and RBF rise markedly
• Glomerular hyperfiltration results in normal reduction in the plasma
creatinine concentration to about 0.4 to 0.5 mg/dL
• Blood urea nitrogen (BUN) and uric acid levels fall for the same reason
Effects of Pregnancy
on Renal Disease
1. ½ cases proteinuria worsen
2. ¼ cases HTN develops
3. Worsening edema if nephrotic
4. 0-10% women with NL or mild reduction in GFR have permanent
decline in renal function
Pregnancy and PE
• Pregnancy is a major cause AKI in women of childbearing age
• AKI and PE may lead to CKD
• PE and HT of pregnancy occur in 3% -10% of all pregnancies
• PE is a Risk Factor for future CKD and ESRD in the mother,
• PE is the principal cause of AKI and maternal death in developing
countries.
• CKD has a negative effect on pregnancy and, given the increase in risk
of CKD progression postpartum
 Criteria for the diagnosis of preeclampsia
Systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on two occasions at
least four hours apart after 20 weeks of gestation in a previously normotensive patient
If systolic blood pressure is ≥160 mmHg or diastolic blood pressure is ≥110 mmHg, confirmation
within minutes is sufficient
and

Proteinuria ≥0.3 grams in a 24-hour urine specimen or protein (mg/dL)/creatinine (mg/dL) ratio ≥0.3

Dipstick 1+ if a quantitative measurement is unavailable

In patients with new-onset hypertension without proteinuria, the new onset of any of the following
is diagnostic of preeclampsia:
Platelet count <100,000/microliter

Serum creatinine >1.1 mg/dL or doubling of serum creatinine in the absence of other renal disease

Liver transaminases at least twice the normal concentrations

Pulmonary edema
Cerebral or visual symptoms

Adapted from: Hypertension in pregnancy: Report of the American College of Obstetricians and Gynecologists' Task Force
on Hypertension in Pregnancy. Obstet Gynecol 2013; 122:1122.
Graphic 79977 Version 9.0
Pregnancy on babies
• PE is associated with intrauterine and perinatal death, preterm
delivery, and restricted intrauterine growth;
• In the long term, small-for–gestational age and preterm babies are at
risk for developing diabetes, metabolic syndrome, CVD, and CKD in
adulthood
• The increased risk of CKD is probably due to low nephron number,
leading to hyperfiltration, hypertension, and reduced resilience after
AKI episodes.
Placental circulation in preeclampsia
Placental release of many cytokines in preeclampsia
Hypertension and pregnancy
• Preeclamsia eclampsia
• Chronic hypertension (present before 20 weeks of pregnancy
• Preeclampsia superimposed on underlying hypertension
• Gestational hypertension (hypertension in after 20 weeks without
prteinuria
Hypertension preeclampsia
• Labetalol is the is the preferred therapy for sever hypertension
• Hydralazine is an acceptable alternative
• Methyldopa and labetalol the first line oral therapy
• Atenolol should be avoided in early pregnancy
Preexisting hypertension
• Has a strong on fetal and maternal outcome
• Preeclampsia 10– 20%
• Preterm birth 12—34%
• Growth retardation 8—16%
• The higher the blood pressure the worse the outcome
Hypertension and pregnancy
• ACE inhibitors and ARBs are contraindicated during pregnancy since
uterine and placental ischemia may occur
• Nitroprusside should be avoided (fetal cyanide poisinig)
Breast feeding
• Beta blockers and calcium channel blockers enter breast milk but are
safe during lactation
• ACE inhibitors and ARBs should be avoided
• Diuretics reduce milk volume and should be avoided
AKI in pregnancy
• Septic abortion (illegal procedure)
• HUS TTP
• HELLP syndrome
• Renal cortical necrosis
• Acute pyelonephritis
• Acute fatty liver of pregnancy
Women with Nephrotic Syndrome
• Discomfort from severe leg edema can be managed with
sodium restriction (1.5 g, approximately 60 mEq), bedrest, and
leg elevation.
• Prophylactic anticoagulation is reasonable in pregnant women
with nephrotic syndrome and severe hypoalbuminemia (serum
albumin <2.0 mg/dL, or <2.8mg/dL in membranous
nephropathy), especially if another risk factor (eg, bedrest) is
present.
• Bile acid sequestrants and fibrates can be safely used in
pregnancy to treat severe hyperlipidemia due to nephrotic
syndrome; statins should be avoided.
Kidney Biopsy During Pregnancy
• There are few Indications for Kidney Biopsy
• May be performed if there is a sudden unexplained deterioration in
renal function or markedly symptomatic nephrotic syndrome
occurring before 32 weeks gestation.
• Biopsy after week 32 is not recommended.
Penyakit Ginjal Kronik
Stadium akhir dengan
hemodialisis

Insiden AKB

2% 50%
Hanya 0-16%
kehamilan >37
Kehamilan
minggu

Ross, et al. 2016

 TUJUAN
mempertahankan usia kehamilan hingga
bayi dapat dilahirkan hidup
 Kehamilan pada PGK mempengaruhi
progresi penyakit ginjal sehingga dapat
terjadi ESRD yg memerlukan HD

Kehamilan pada PGK dgn HD reguler jarang

terjadi
PGK pada kehamilan mempengaruhi
luaran kehamilan  dapat terjadi lahir
premature, BBLR atau kematian janin
Brown, et al. 2015
Pengaruh Kehamilan pada PGK
Persentase Menjadi ESRD
PGK ringan (SC: < 1,5 mg/dL) 
Jarang
PGK sedang (SC: 1,5-2,4 mg/dL) 
6%
PGK berat (SC: ≥ 2,5 mg/dL) 
45%
Ramin et al., 2006 ;Brown, et al. 2015
 Etiologi PGK pada Kehamilan

Glomeru Lupus Nefropati Ginjal

DM 1 lonefritis nefritis IgA polikistik

Chao et al., 2002; Ramin et al., 2006

Kehamilan pada PGK dengan Hemodialisa

Parameter Keberhasilan
melahirkan bayi yang bisa bertahan hidup (viable)

• Awalnya angka keberhasilan hanya 23% 

meningkat 80-100%

Ross, et al., 2016; Piccoli et al., 2010

Kehamilan pada PGK dengan Hemodialisa

Luaran pada Fetus

lahir prematur, berat badan lahir rendah (BBLR), Intra Uterine
Growth Retardation (IUGR) & polihidramnion

Faktor risiko lahir prematur  hipertensi berat, anemia, uremia

Faktor risiko IUGR & BBLR  hipertensi berat, anemia, ekspansi

volume cairan saat kehamilan

Polihidramnion  uremia (terjadi solute diuresis pada fetus)

Ross, et al., 2016; Piccoli et al., 2010

Kehamilan pada PGK dengan Hemodialisa

Luaran pada Fetus

lahir prematur, berat badan lahir rendah (BBLR), Intra Uterine
Growth Retardation (IUGR) & polihidramnion

Ross, et al., 2016; Piccoli et al., 2010

 Hemodialisa

• Pilihan pertama
• HD vs CAPD = 78.6% vs 33.3%
• Dosis min : 20 jam/minggu  semakin banyak semakin baik
• memperpanjang umur kehamilan
• meningkatkan berat badan lahir bayi

Manisco, et al., 2015; Hou et al., 2008

 Cairan Dialisa

Cairan Asetat
Cairan Bikarbonat
• Dapat meneteralkan asidosis
• Tidak menyebabkan vasodilatasi

Picoli, et al., 2010; Brown, etal., 2015

 Perdarahan

Resiko heparin induced trombositopenia

Maternal
Osteoporosis
Tdk menembus plasenta
Penggunaan Janin
Aman bagi janin
HEPARIN
Kasus

Dhir, 2010
 ANEMIA

Target Perbaikan Pilihan Terapi

• Transfusi dengan PRC
Hb
• Suplementasi besi oral
10-11g/dl • Besi Intravena
Hct • Rekombinan Eritropoetin (EPO)
30-35% Penggunaan EPO  tidak menembus
plasenta dan tidak teratogenik

Reddy, et al. 2007

 HIPERTENSI
Eklampsi
Pilihan Terapi
• Metyldopa (2 x 250)
Target • Labetalol
140/90 • Nifedipin

Fetal
distres

Mannisco, et al. 2015

Rekomendasi Intervensi Pada Hemodialisis dalam Kehamilan (Manisco et al., 2015)
Kontrol Tekanan Darah
- obat yang dihindari: diuretic,ACE inhibitor, ARB
- obat yang dipilih: metildopa, labetalol, nifedipine, nicardipoine, verapamil
- Target tekanan darah diastolik 80-90 mmHg
- Hindari hipotensi dan penurunan volume

Hindari terjadinya asidosis metabolik

Intensifkan hemodialisis
- Peningkatan frekuensi sesi hemodialisis (5-7 kali/minggu)
- Target BUN < 16-18 mmol/L
- Peningkatan berat badan ibu 1-1.5 kg pada trimester pertama dan 0.45-1 kg per minggu pada trimester terakhir

Gunakan dosis minimal heparin yang mungkin

Gunakan membrane yang biokompatibel
Kontrol metabolism Kalsium dan Fosfat
- Hindari hiokalsemia dan hiperfosfatemia
- Berikan suplementasi kalsium 1.5-2 gram/hari, diet kalsium 800 mg/hari dan kadar kalsium dialisat 1.5 mmol/L
- Jika diperlukan, berikan vitamin D. Hindari hiperkalsemia pasca dialysis

Koreksi Anemia
- Berikan suplementasi besi (10-15 mg/hari) dan asam folat (1 mg/hari)
- Tingkatkan dosis EPO 50-100%
- Target Hb 10-11 gr/dL. Hematokrit 30-35% dan kadar ferritin 200-300 µg/mL
Nutrisi
- Berikan protein 1,2-1,4 gram/kg berat badan sebelum hamil/hari + 20 gram/hari
- Berikan kalori 25-35 kkal/kg berat badan hamil/hari
- Berika suplementasi vitamin larut dalam air
KEHAMILAN PADA PGK DGN HD REGULER

Sangat jarang terjadi (diketahui ketika UK 14 minggu)

Gejala menyerupai asites dan hiperemesis

FAKTOR PENURUNAN FERTILITAS

Peningkatan kadar prolaktin, LH
Perubahan pulsasi GnRH
Malnutrisi, def vitamin dan mineral
Konsumsi obat obatan

Penggunaan EPO dapat meningkatkan fertilitas

Giatras, et al. 1998

 KONTRASEPSI

Metode penghalang Dapat digunakan secara aman

IUD Infeksi dan perdarahan selama hemodialisa

Kontrasepsi oral • Aman jika tidak disertai hipertensi, DM, dan

lupus
• Mengurangi resiko osteodistrofi renal

Giatras, et al. 1998

TERIMA KASIH
 Effect of CKD on Pregnancy
• Miscarriage
• Gestational hypertension in 50%
• PE (if mild CKD risk=20%, if severe Creatinine > 180 =
60% )
• IUGR (if severe 65%)
• Fetal death (with urea >20-25 mmol/L: 10%)
Distribution of gestational
age and birth weight of
live births according to
timing of conception
before dialysis (CBD) or
conception on dialysis
(COD).
 Why don’t uremic women
get pregnant?
• Most beyond child bearing age  only 3-10% women of child
bearing age
• Libido/ frequency of intercourse reduced
• Amenorrhea, Don’t ovulate or anovulatory menstrual cycles, early
menopause
• Absence of increase in basal body temperature during the luteal
phase of cycle
• Elevated circulating prolactin dan LH concentrations
• Decreased FSH, progesteron and estradiol
 Common Themes in Dialysing Pregnant
Patients

1. Keeping BUN < 50

2. Increasing dialysis time and frequency
3. BP control
4. Managing anemia with increasing doses of ESA
5. Fetal monitoring once viability reached
 BUN <50 Hypothesis?
• 1963 150 women varying degrees of CKD, none on dialysis,
found the single most important factor influencing fetal outcome
was BUN
• Fetal mortality directly proportional to BUN
• Hypothesis: intensive dialysis in pregnant women w/renal dz
might improve fetal outcomes
 Increasing frequency and
time on dialysis?
• May be beneficial in reducing incidence of polyhydramnios by
reducing urea and water load
• Less dialysis-induced hypotension
• More liberal diet
 Should we Initiate Dialysis in Pts w/Low Cr
Clearance?
• Hou, S., Pregnancy in Women on Hemodialysis, 1994, revealed
better outcomes of pregnancy in women w/ significant residual
renal function or who initiate pregnancy before they need dialysis.
• May reduce incidence of polyhydramnios, lower urea and lowers
water load, also reducing risk of dialysis-induced hypotension
 Women who Start Dialysis
During Pregnancy
• Likelihood of infant surviving is good
• Termination of a pregnancy after renal function has begun to
deteriorate rarely rescues the kidneys
• NEJM, Jones and Hayslett, 1996, looked at 82 pregnancies in 67
women w/CRI, only 15% of those w/deteriorating renal function
had a return of renal function to baseline in 6 mths post partum
Hou, et al, 1998
Hou, et al, 1998
Hou, et al, 1998
Comprehensive Clinical Nephorlogy. 5th edition. 2015

Yuvaraj et al. Indian Journal of Peritoneal Dialysis. 2015

NICE Guidelines 2010
NICE Guidelines 2010