Written Case Study

Renal Disease and Pregnancy

By: Sydney Flippo
ECU Dietetic Intern
Spring 2014
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Table of Contents:
I. Review of Literature 3-5
II. Discussion of the Disease 5
III. Patient Data 6
IV. Medical, Surgical and Other Treatments 6-7
V. Nutrition Care Process 7-11
VI. Prognosis 11-12
VII. Summary 12
VIII. References 13
IX. Appendix: Definitions 14








































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I. Review of Literature
During normal pregnancy blood volume and red blood cell mass increased by up to 50%
(4). Systemic vascular resistance falls and cardiac output increases by up to 30% (4). Renal
blood flow increases by 50%, glomerular filtration rate (GFR) increases by 30%, and serum
creatinine decreases by 20% (4). An increase in GFR changes glomerular hemodynamics and
alters renal tubular function, which leads to an increase in urine protein excretion (4). During
normal pregnancy, urine protein excretion can reach 260 mg/d (4). Because of this increase in
urine protein excretion, normal means of measuring GFR are not reliable, so serum creatinine
concentration is used to identify renal dysfunction.
Women with chronic kidney disease are less able to make the renal adaptations needed
for a healthy pregnancy (6). Their inability to boost renal hormones often leads to normochromic
normocytic anemia, reduced expansion of plasma volume, and vitamin D deficiency (6). The
gestational rise in glomerular filtration rate is blunted in women with moderate renal impairment
and usually absent in those with a serum creatinine higher than 200 mol/l (6). If preeclampsia
develops, maternal renal function often deteriorates further (6). Maternal hypertension,
proteinuria, and recurrent urinary tract infection often coexist in women with chronic kidney
disease (6). Women with severe renal impairment have the greatest difficulty conceiving, the
highest rate of miscarriage, and the poorest pregnancy outcome (6). Breast feeding should be
encouraged in women with chronic kidney disease (6).
Women with mildly elevated creatinine, in the range of 1.21.4 mg/dL before pregnancy,
have a small risk for a decline in renal function (1). Those with moderate renal insufficiency
(serum creatinine 1.42.5 mg/dL) are at 2030% increased risk of preeclampsia and preterm
delivery (1). Of these women with moderate renal insufficiency, approximately 50% have a
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pregnancy-related decrease in creatinine clearance of 25% or more, which may persist or worsen
after delivery (1). Women with severe renal dysfunction, defined as a creatinine concentration
>2.5 mg/dL, should be discouraged from conceiving because 70% will experience preterm
delivery, 40% will develop preeclampsia, and 40% will experience pregnancy or postpartum
deterioration in renal function necessitating dialysis (1).
Because of infertility and the high rate of early pregnancy failure in women with a serum
creatinine >1.9 mg/dL, little information exists regarding fetal outcomes (3). When pregnancy
does occur, prematurity, low birth weight, and neonatal death are more the rule than the
exception (3). In a comparison of moderate with severe kidney disease groups, adverse fetal
outcomes were clearly linked to the degree of kidney functional impairment (3). With moderate
kidney disease, the proportion of preterm delivery was 55% and intrauterine growth retardation
was 31% (3). In the setting of severe kidney disease, preterm delivery occurred 73% of the time
and intrauterine growth retardation 53% of the time (3). Mean fetal birth weight was 1,520 g in
the setting of severe maternal kidney disease and 2,500 g in moderate kidney disease, whereas
preterm delivery rose from 30% in moderate maternal kidney disease to 86% in severe maternal
kidney disease (3). Hypertension is even more frequent with moderate and severe kidney disease,
present in more than 50% of such pregnancies (3). The development of hypertension leads to a
greater likelihood of GFR deterioration (3).
Diabetic nephropathy is the most common etiology for end-stage renal disease (5). It
complicates approximately 5% of insulin-dependent diabetic pregnancies (5). Women with
diabetic nephropathy have a significantly reduced life expectancy (5). The need to establish a
level of glycemic control in diabetic women to reduce risks for fetal malformations is well
established (5). A consistent increase in preterm delivery with rates exceeding 50% and fetal
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growth restriction in 15% of cases has been reported in American and European series over the
last 25 years (5). Rates of preeclampsia often exceed 50% and cesarean delivery occurs in 70%
of cases (5). Women with initial serum creatinine exceeding 1.5 mg/dL have an increased risk of
preterm delivery, lower birth weight, preeclampsia, and cesarean delivery (5).
II. Discussion of the Disease
1. Incidence and etiology
The incidence of renal disease in pregnancy is approximately 2 in 10,000
women. Renal disease occurs in five stages. In renal disease, the kidneys
start shutting down and filtration is impaired.
2. Signs and symptoms
Signs and symptoms include: decreased urinary output, edema, lack of
appetite, nausea and vomiting, feeling confused, anxious and restless or
sleepy, pain in the back just below the rib cage.
3. Methods of physician diagnosis
Blood and urine tests are used to check kidney function. Blood work
checks for levels of sodium (salt), potassium, and calcium. It can also
check for glomerular filtration rate. An ultrasound may also be used too.
4. Treatment and preventive prophylaxis
Treatment includes the use of diuretics, in some cases dialysis and dietary
changes. Preventative prophylaxis is dietary changes to reduce sodium,
potassium, phosphorous, calcium, and protein restriction in some cases
5. Usual prognosis: The outcome for mother with kidney disease and her
fetus are not good. There are many complications that can occur.
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III. Patient Data:
A. NR is a 31 y.o. African American female G6P104 at 21 weeks 2 days pregnant.
B. Medical diagnosis include: pregnancy, chronic anemia, hypertension, acute on
chronic renal failure, diabetes, and bipolar disorder. Diets varied during
admission, but usually consisted of sodium restricted, consistent carbohydrate diet
with a dietary supplement.
C. Socio-economic background
1. African American, Female
2. Family
a. One Adult in the household- renal disease
b. One Child in the household- healthy
3. No job; frequents a homeless shelter in the area. Also lives with sister on
occasion.
4. Some high school education
5. Usually inactive
IV. Medical, Surgical and Other Treatments
1. Past Medical History: psychiatric illness, DM type 2, HTN, DVT of LLE,
history of stomach ulcers, anemia, CKD, blood transfusion, CAD-
enlarged heart, postpartum depression.
2. Present illness and diagnosis/etiology
a. Problem list: Abdominal pain, edema, acute on chronic renal
failure, proteinuria, metabolic acidosis, type 2 DM, HTN, chronic
anemia, respiratory failure 2/2 pulmonary edema, preeclampsia
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and bipolar disorder.
b. Clinical and laboratory findings of significance: 11/08/13: Na-
133, K-5.2, Cl- 112, Creatinine- 2.3, and Albumin-0.5. 11/20/13:
Cl- 113, Creatinine- 2.0, and Albumin- 0.7. 11/30/13: Cl- 121,
Creatinine- 2.1, and Prealbumin- 18.6. 12/04/13: Cl- 112,
Creatinine 2.5, and Albumin 1.0. 12/10/13: Cl- 114, Creatinine-
1.8, and Albumin- 1.2. 12/26/13: Cl- 114, Creatinine- 3.2, and
Albumin- 1.6. 01/17/14: Cl- 109, Creatinine- 3.7, Albumin 0.9, and
Prealbumin- 9.9.
3. Relevant physician's orders: daily weights
a. Medications: calcium, Lasix, insulin, morphine, Zofran, prenatal
vitamin, protonix, propofol, iron, and sodium bicarbonate.
b. Surgical procedures: After stabilization and steroid maturation of
the fetus, she underwent a C-section (fetus at 27 weeks gestation)
with serosal tear, repair of small bowel tear and bilateral tubal
ligation
V. Nutrition Care Process
Assessment
1. Typical diet before hospitalization: non-compliant with diabetic or renal
diet.
2. Current diet: Originally consistent carbohydrate, changed to tube feeding
while intubated, changed back to consistent carbohydrate, added a sodium
restriction to the consistent carbohydrate for control of preeclampsia.
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3. Nutrient Needs:
Ht: 52 (1.575m)
Wt: 222lb 3.6oz (100.8kg)
Per-pregnancy wt: 150 lbs (68kg)
IBW: 110lbs + 15lbs= 125lbs (57kg)
%IBW: 136%- prepregnancy
ABW: 54.5kg- prepregnancy
BMI: 27.4kg/m2-prepregnancy

Estimated Energy Needs:
Kcal/kg/day: 23-30 kcal/kg ABW + 300kcal
Total kcal/day: 1665-1935
Estimated Protein Needs:
Gm/kg/day: 1.2-1.4g/kg ABW + 10grams
Total gm protein/day: 75-86

Post Cesarean Needs:

Estimated Energy Needs:
Kcal/kg/day: 26-28
Total kcal/day: 1430-1540
Estimated Protein Needs:
Gm/kg/day: 1.0-1.2
Total gm protein/day: 55-66
Nutrition diagnosis/es
i. Inadequate oral intake related to lack of appetite as evidence by pt report
ii. Inadequate oral intake related to lack of appetite as evidence by
observation and pt report
iii. Swallowing difficulty related to mechanical ventilation as evidence by
ETT in place
iv. Increased nutrient needs related to pregnancy as evidence by 22 weeks
gestation
v. Inadequate oral intake related to nausea as evidence by 25% of meals
consumed and patient report of poor intake
vi. Increased nutrient need related to pregnancy as evidence by 24 weeks
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gestation
vii. Inadequate oral intake related to diet restriction as evidence by clear liquid
diet only
viii. Inadequate oral intake related to lack of appetite as evidence by oral intake
reports
ix. Increased nutrient needs related to s/p surgery, catabolic illness as
evidence by recent C-section with complications, low pre-albumin
Intervention:
i. Reviewed healthy nutrition for pregnancy and provided handout, answered
questions. Encouraged balanced intake as tolerated. Continue magic cups
for extra calcium, protein and calorie while appetite decreased.
ii. Continue with consistent CHO diet and change Boost Breeze to Boost
Glucose Control supplement
iii. Consult for TF- Start Novasource Renal @ 30ml/hr + 5 packets
beneprotein + propofol providing 2357 kcal, 94 g protein, and 800 ml free
water (34 kcal and 1.3g protein /kg ABW): Propofol@ 30 ml/hr (792kcal)
iv. Continue current TF rate for now due to uncertain rate that propofol will
resume
v. Will check indirect calorimetry and adjust regimen as needed
vi. Continue current TF rate matching indirect calorimetry goals. Will
decrease beneprotein to 3 packets per day to better meet protein needs
(82g Protein including TF, 1834 kcal)
vii. If decreased potassium continues, can switch formula to peptamen 1.5 @
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40 ml/hr and continue with 3 packets beneprotein to meet needs.
viii. Recommend advancement of diet as tolerated to consistent carbohydrate +
any additional restrictions per speech therapy
ix. Will add PO supplements of Boost Breeze due to poor PO intake prior to
admission and increased needs with pregnancy
x. Continue diet per speech pathologist
xi. Will continue to send Boost Breeze with meals
xii. Encourage intake of meals
xiii. Continue current diet- pt using room service system to select preferred
foods
xiv. Educated pt on diabetic diet during pregnancy- eating well rounded meals,
snacks b/t meals and controlling the amount of carbohydrates she
consumes in one sitting. Provided handouts.
xv. If K+ levels continue to worsen may need to restrict potassium in diet
xvi. As bowel fxn returns suggest advancement to consistent CHO renal diet
xvii. Continue current diet rx and PO supplements
xviii. Continue current diet as tolerated
xix. Will continue supplements of Boost Breeze BID
xx. Continue current diet as tolerated
xxi. Will continue supplements of Boost Breeze BID
xxii. Encourage pt to eat well when going home this week
Monitoring and Evaluation:
i. MNT Goal: optimal PO intake >75% of meals
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1. Will monitor nutrition parameters, clinical course, plan of care
ii. MNT Goal: Pt will meet needs via enteral nutrition
1. Will monitor nutrition parameters, clinical course, plan of care
iii. MNT Goal: Pt will consume at least 50% of meals and supplements with
good tolerance
1. Will monitor pt status, PO intake, diet tolerance, plan of care
iv. MNT Goal: Pt consuming 100% of meals and snacks on consistent CHO
diet
1. Will monitor pt status, PO intake, diet tolerance, plan of care
v. MNT Goal: Pt able to tolerate diet advancement to solid foods
1. Will monitor pt status, PO intake, diet tolerance, plan of care
vi. MNT Goal: Pt will consume at least 50% of meals w/ supplements
1. Will monitor pt status, PO intake, diet tolerance, plan of care
vii. MNT Goal: to consume 60% of diet and supplements
1. Will monitor intake of diet and supplements and adjust as needed
2. Will monitor labs, protein status, fluids and renal labs
3. Will monitor progress of condition, plan of care
VI. Prognosis
The prognosis for the patient is questionable. She underwent major surgery and insult to
her kidneys. It is not likely that her kidney function to return to baseline. She was
previously non-compliant with her consistent carbohydrate diet. It is unlikely that she
will be compliant with the consistent carbohydrate and renal diet, especially since the diet
is very difficult to adhere to. NR will likely end up on dialysis. The baby was born at 27
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weeks gestation and admitted to the NICU. If the baby receives proper nutrition, it is
likely that the prognosis is good.
VII. Summary
This was a very interesting case. It is not very often that you get to see a pregnancy
complicated by kidney disease. This was a very complicated case initially further
complicated by the many medical problems that arose. Her case was also complicated by
the fact that she left against medical advice numerous times. We could have improved
NRs care by only offering supplements that were appropriate for renal disease.















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VIII. References
1. Chinnappa, V., Ankichetty, S., Angle P., and Halpern, S.H. Chronic kidney disease in
pregnancy. International journal of obstetric anesthesia. 2013; 22:223-230.

2. Davidson, JM. And Lindheimer, MD. Pregnancy and Chronic Kidney Disease. Seminars
in Nephrology. 2011; 31(1):86-99.

3. Fisher, M.J. Chronic Kidney Disease and Pregnancy: Maternal and Fetal Outcomes.
Advances in Chronic Kidney Disease. 2007; 14(2):132-145.

4. Hall, M. and Brunskill, N. Renal disease in pregnancy. Obstetrics, Gynecology and
Reproductive Medicine. 20(5):131-137.

5. Landon, MB. Diabetic Nephropathy and Pregnancy. Clinical Obstetrics and Gynecology.
2007; 50(4):998-1006.

6. Williams, D. and Davidson, J. Pregnancy Plus: Chronic Kidney Disease in Pregnancy.
British Medical Journal. 2008; 336(7637): 211-215.





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IX. Appendix: Definitions
Definitions:
Blood Volume- the amount of blood in the human circulatory system
Red Blood Cell Mass- the amount of red blood cells in the body
Systemic Vascular Resistance- the resistance to flow that must be overcome to push blood
through the circulatory system
Cardiac Output- the amount of blood that pumps through the heart in one minute
Glomerular Filtration Rate- the rate at which filtered fluid moves through the kideys
Normal Serum Creatinine- 0.6-1.3 mg/dL
Type 2 DM- Type 2 diabetes: a metabolic disorder that is characterized by high blood glucose in
the context of insulin resistance and relative insulin deficiency
HTN- hypertension: abnormally high blood pressure
DVT of LLE- deep vein thrombosis of the left lower extremity: blood clot in the deep veins of
the legs
CKD- chronic kidney disease: a progressive loss in renal function over a period of months or
years
CAD- coronary artery disease: a narrowing of the small blood vessels that supply blood and
oxygen to the heart
C-section- cesarean section: a surgical operation for delivering a child by cutting through the
wall of the mother's abdomen