Kidney failure during pregnancy. What is the danger of kidney failure during pregnancy and what to do about it? What forms of development of pathology exist?

Keywords

CHRONIC KIDNEY DISEASE / CHRONIC RENAL FAILURE/ PREGNANCY / CHRONIC KIDNEY DISEASE / CHRONIC RENAL FAILURE / PREGNANCY

annotation scientific article on clinical medicine, author of the scientific work - Nikolskaya Irina Georgievna, Prokopenko Elena Ivanovna, Novikova Svetlana Viktorovna, Budykina Tatyana Sergeevna, Kokarovtseva Svetlana Nikolaevna

Pregnancy in women with kidney disease, even with preserved renal function, is accompanied by an increased incidence of obstetric and perinatal complications compared to population indicators, such as preeclampsia, premature birth, the need for surgical delivery, and intensive care for newborns. The article presents our own data on complications and pregnancy outcomes in 156 women with different stages chronic kidney disease(CKD). Of these, 87 patients were with CKD stage I, 29 with CKD stage II and 40 with CKD stages III, IV, V, combined into the diagnosis " chronic renal failure"(CRF). For the first time in Russia, the authors summarized the unique experience of managing pregnancy with chronic renal failure, emphasized the high probability (27.5%) of its primary diagnosis during pregnancy, presented algorithms for the examination, prevention and treatment of various gestational complications in chronic renal failure (preeclampsia, urinary tract infections, fetoplacental insufficiency, anemia, acute kidney injury), as well as the effect of pregnancy on kidney function in the late postpartum period. A direct correlation has been proven between the stage of CKD, the incidence of preeclampsia, fetoplacental insufficiency, premature birth, surgical delivery by cesarean section, and the condition of children at birth. Based on a large clinical material, the probability of a favorable pregnancy outcome in patients with chronic renal failure with stable renal function and in the absence of severe arterial hypertension during pregnancy has been proven: for the child in 87%, for the mother in 90% (preservation of the same stage of CKD). The risk of persistent decline in kidney function during pregnancy and the postpartum period in women with chronic renal failure increases with stage IV CKD and in the case of early onset of preeclampsia, and also correlates with its severity. The likelihood of a favorable obstetric and “nephrological” outcome increases when planning pregnancy and intensive joint management of patients by an obstetrician-gynecologist and a nephrologist from the early stages of pregnancy.

Complications and outcomes of pregnancy in chronic kidney disease

Pregnancy in women with kidney disorders, even with preserved renal function, is associated with higher than in the population rates of obstetric and perinatal complications, such as eclampsia, preterm delivery, surgical deliveries and intensive care for newborns. This article presents our own data on complications and outcomes of pregnancies in 156 women with various stages of chronic kidney disease (CKD). From these, 87 patients had CKD stage I, 29 with CKD stage II and 40 with CKD stages III, IV, V. For the first time in Russia, the authors summarize their unique experience in management of pregnancy with CKD, underline a high probability (27.5%) of its primary detection during pregnancy, discuss the algorithms of assessment, prevention and treatment of various gestational complications in CKD (pre-eclampsia, urinary tract infections, feto-placental insufficiency, anemia, acute renal damage), as well as the influence of pregnancy on renal function at long-term post-delivery. A direct correlation between the CKD stage, frequency of pre-eclampsia, feto-placental insufficiency, preterm deliveries, surgical deliveries by caesarean section and babies"" status at birth is demonstrated. Based on their ample clinical material, they confirm the probability of favorable pregnancy outcomes in CKD patients with stable renal function without severe arterial hypertension during pregnancy: for a baby in 87%, for the mother in 90% (maintenance of the same CKD stage). The risk of persistent deterioration of renal function during pregnancy and puerperium in women with CKD is higher in CKD stage IV, as well as in the case of early development of pre-eclampsia; it also correlates with severity of the latter. The probability of a favorable obstetric and nephrological outcome is higher when the pregnancy is planned and intensively co-managed by an obstetrician/gynaecologist and a nephrologist from early weeks of gestation onwards.

Kidney failure is a life-threatening and health-threatening condition for the expectant mother and child. When neglected, it leads to irreversible processes: disruption of hemostasis, acid-base and water-salt metabolism, intoxication of internal organs, and a high percentage of deaths.

a brief description of

Renal failure (RF) is a pathological process of the urinary system. In which the death of nephrons and the inability of the renal parenchyma to perform the functions assigned to it are noted.

The kidneys completely or partially lose their main function - excretory. Excretion of end products of metabolism in urine. Depending on the stage and type of disease.

There are acute and chronic forms of the disease. The acute form is an acute violation of the filtration capacity of one or two kidneys as a result of exposure to exo- and endogenous negative factors. Chronic PN is the gradual death of nephrons.

The most dangerous disease is diagnosed during pregnancy. Women with kidney pathologies are at risk for complicated pregnancy and childbirth.

Pregnancy with chronic renal failure

Carrying a child with chronic renal failure carries many risks for the fetus and mother.

Progressive depression of renal function leads to female body imbalance and fatal changes in the process of hemostasis.

In severe and acute cases, women are prohibited from becoming pregnant and giving birth to children, because the load on the urinary system and, in particular, the kidneys increases.

When planning a pregnancy, specialists thoroughly examine the patient and issue a “verdict.”

Chronic kidney failure can cause:

(up to 28 weeks of pregnancy);
fetus;
Stillbirth;
Blood loss;
child and difficult postpartum recovery period.

Pregnancy and acute renal failure

Acute renal dysfunction during pregnancy is diagnosed in the first and last trimester of gestation.

Kidney failure develops sharply and rapidly, threatening the life and health of the pregnant woman and the fetus.

An increase in the amount of toxic chemical components (uric acid, urea and creatinine) is associated with provocative factors in the development of the pathological process.

Causes, development and complications

During pregnancy, changes are observed in the female body: immune defense decreases, diseases appear that the woman had not previously suspected.

The pressure exerted by the fetus on all internal organs forces the body to work in double mode. The process is aggravated by acute or chronic forms of renal failure.

The main factors provoking the development of chronic renal failure in pregnant women:

Diseases that cause damage to the glomerular system. , glomerulonephritis and in the chronic stage, rheumatic diseases and arterial.
advanced acute form of renal failure.

Causes of acute renal failure in pregnant women:

malignant neoplasms of the pelvic organs;
established pyelonephritis before the gestational period;
postpartum consequences (blood loss, abortion in late stages of gestation, antenatal death of the fetus and its long stay in the uterine cavity;
cystitis (possible development of a postrenal form of the disease);
curettage of the uterine cavity with non-sterile instruments;
and drug poisoning;
operations with red blood cells with inappropriate ;
urinary system injuries;
sharp to a greater extent.

Forms of acute renal failure

The development of acute renal failure occurs in different ways, depending on the diagnosed form of the process:

prerenal– resulting from a violation of the blood supply to the organ;
renal– characterized by the development of a violation of the functional duties of organ cells;
postrenal– develops when the urinary ducts are blocked. Stones or .

Consequences (complications) as a result of kidney failure in pregnant women, regardless of stage:

premature birth;
threat of miscarriage;
the child's subsequent stay in intensive care wards to eliminate
negative consequences;
impaired hemostasis, which threatens extensive blood loss on the part of the mother;
for long periods;
threat of sepsis and uremic coma;
myocardial or cerebral ischemia;
swelling of the limbs;
if treatment is refused, death will occur.

Symptoms of the disease

Chronic renal failure during pregnancy - symptoms

latent phase (hidden): fatigue, weakness, dry mouth. Minor abnormalities in urine analysis;
compensated phase: increased diuresis to 2.5 l, severe apathy and weakness;
intermittent phase: persistent changes in nitrogen metabolism in the biochemical analysis of venous blood. Nausea, vomiting, tremors, increased thirst and unpleasant taste in the mouth. The skin turns yellow and a specific urinary odor appears.
terminal phase: complete absence of urine, puffiness of the face, the skin acquires a gray-yellow tint, and the act of defecation is disrupted. Fatal disorders of the internal secretion organs, nervous system disorders, encephalopathy, irreversible changes in the coagulation system.

Acute renal failure during pregnancy - symptoms

nagging pain in the lower back;
cessation of urine output;
adynamia;
lethargy;
azotemia;
body hyperthermia;
muscle weakness;
change in the color of urine (when it is excreted);
arrhythmia;
“uremic” smell from a pregnant woman;
change in skin color.

A pregnant woman can determine the initial symptoms herself and immediately contact a gynecologist.

Diagnostics

Symptoms of the development of the pathological process are not enough to make a diagnosis, so a number of diagnostic procedures are performed:

with quantitative determination and microscopic examination of urine sediment.
Expanded capillary blood + ESR.
Biochemical blood test. Required: glucose, protein, urea, uric acid and creatinine. It would be useful to determine CRP and procalcitonin, as well as the acid-base composition of the blood.
Bacteriological examination of urine.
Venous blood examination.

Laboratory research allows you to determine the type and type of pathological process. But for the final diagnosis, an emergency is carried out.

Treatment

Kidney failure is detected and treated by urologists or nephrologists. Specialists choose the tactics and treatment regimen.

There are no drugs for PN. Treatment involves the complex use of medications approved during gestation.

Drug therapy:

Anti-inflammatory drugs (Canephron).
Drugs that prevent intoxication (for example, a group of sorbent drugs).
Antibiotic therapy (Amoxiclav, but if the bacteria are sensitive to this type of antibiotic).
Taking antiviral drugs (feron-containing drugs).
Anabolics.
Antifungal drugs if necessary.

Surgical intervention is possible, and in a critical situation, transfusion of blood, plasma and formed elements.

The chronic form of PN during pregnancy (and in principle) cannot be cured. For normal prolongation of pregnancy, an individual treatment regimen for the patient is selected.

Diet for kidney failure is part of a comprehensive treatment.

Drink plenty of fluids (at least 2.5 liters per day, excluding liquid foods).
Restriction: milk, mushrooms, nuts, cocoa, white bread.
Limited intake of “animal” protein.
Foods high in potassium (bananas, dates, raisins).

Allowed:

lean boiled fish;
milk soups;
berries and fruits;
lean meat (steamed or boiled);
raw vegetables (not all).

Cooking meals for acute renal failure and chronic renal failure should be accompanied by a complete abstinence from salt.

Postpartum acute renal failure

In the postpartum period, the likelihood of developing an acute form of renal pathology remains. The disease can make itself felt a few days after birth, or after several weeks.

Causes: blood loss and infection of the birth canal.

Symptoms: hyperthermia, difficulty urinating, lack of appetite and pain in the abdominal cavity. Hepatomegaly is possible.

In severe situations – disturbance of cardiac activity and respiratory process. The increased risk of death is due to the lack of treatment, but timely measures taken save the life of the new mother.

Video: kidney failure during pregnancy

Pregnancy is an amazing period in a woman’s life. Her body is changing, new taste preferences and habits are being formed. However, the expectant mother’s body is not always able to bear a baby without medical help. Some serious disturbances in the functioning of the genitourinary system can lead to the fact that the kidneys simply stop functioning. Renal failure during pregnancy is a dangerous pathology that requires immediate intervention from specialists when diagnosed. Therefore, during pregnancy it is very important to closely monitor your health and undergo regular examinations.

Types of kidney failure

There are acute and chronic forms of the disease. In case of a chronic course, it is very important, even at the planning stage, to contact specialists who, based on the results of tests and studies, will be able to assess the chances of a successful pregnancy and childbirth. Unfortunately, medicine is also aware of cases where, due to serious complications, doctors were forced to terminate a pregnancy at an early stage in order to save the woman’s life. In later stages, emergency delivery is carried out in situations associated with the risk of bleeding in the mother and intrauterine fetal death, as well as in the presence of other abnormalities requiring surgical intervention.

Since the kidney is a kind of filter for the human body, additional load on this organ can lead to the appearance and development of diseases such as:

Pyelonephritis (kidney inflammation);
glomerulonephritis (damage to the glomeruli);
formation of stones and the presence of sand in the kidneys and ureter;
cystitis (bladder infection).

All of the above painful conditions can provoke acute renal failure in pregnant women. The development of this type of disease is most often diagnosed in the first and last trimester. Depending on the symptoms, prerenal, renal and postrenal forms are determined.

Signs of the disease

In addition to pain in the area where the kidneys are located, against the background of a general deterioration in well-being, swelling of the lower extremities, drowsiness, and fatigue are also possible. Complaints of severe headache and high blood pressure, difficult and painful urination, dry mouth, nausea and repeated vomiting, in turn, are a reason to immediately contact the antenatal clinic or the nearest clinic. If a patient with a history of any diseases, one way or another related to the kidneys, is not promptly provided with all the necessary assistance for such symptoms, then the probability of death is almost 100%. Failure of one or both kidneys simultaneously leads to severe intoxication of the body. The state of pregnancy against the background of the general clinical picture only aggravates the situation.

Establishing diagnosis

Kidney failure during pregnancy can be determined by several types of tests. Typically, a urologist writes out referrals for a general blood and urine test, blood biochemistry and urine microbiology. Ultrasound diagnostics is also a mandatory item on this list. Ultrasound helps identify kidney and bladder diseases at their initial stages.

Treatment methods

After the disease is diagnosed, the doctor will prescribe complex therapy. Since not all medications intended to relieve pain and eliminate the causes of their occurrence can be used while waiting for a baby, urologists are very careful when prescribing many medications. The main methods of treatment in this case are:

Nutrition adjustments. In case of kidney failure, patients are advised to drink at least 2 liters of water daily and eat foods that are easily absorbed by the body. It is advisable to exclude white bread products and products rich in potassium from the diet.
Medication support. To prevent the consequences of intoxication, drugs are used that remove toxins from the body. "Canephron" and "Brusniver" have an anti-inflammatory effect and do not have any negative effect on the fetus. However, this does not mean that you can take them on your own!

It is strictly prohibited to use any medicines on your own initiative!

Unfortunately, the chronic form of the disease cannot be cured. To relieve symptoms and stabilize the general condition of the body, the doctor may prescribe systematic dialysis. In addition, the patient is strictly prohibited from any type of physical activity and bed rest is indicated in case of exacerbation.

Complications of kidney failure

Delayed diagnosis can lead to the acute form of the disease progressing to an incurable (chronic) stage. In addition to such disappointing prognoses, there is a risk of developing uremic coma and sepsis.

Even if a woman has no apparent reason to worry, planning a pregnancy is an ideal scenario. With this approach, you can avoid many serious health problems even before conception, because the expectant mother is responsible not only for herself, but also for the little representative of the new generation.

Chronic renal failure (CRF) is the final phase of the development of many chronic kidney diseases, characterized by a persistent and irreversible decrease in the mass of functioning nephrons and manifested mainly by a decrease in the excretory function of the kidneys.

CRF is a relatively common syndrome. It is a consequence of excretory and endocrine hypofunction of the kidneys. The most important indicators of chronic renal failure are the retention of creativity in the body, its clearance (purification coefficient, measured by glomerular filtration) and blood pH. In various kidney diseases, the pathological process mainly affects the glomerular or tubular part of the nephron. Therefore, a distinction is made between CRF of the predominantly glomerular type, which is characterized primarily by hypercreatininemia, and CRF of the tubular type, which initially manifests itself as hyposthenuria.

The kidney has great compensatory capabilities. The death of even 50% of nephrons may not be accompanied by clinical manifestations, and only when glomerular filtration drops to 40-30 ml/min (corresponding to a decrease in the number of nephrons to 30%) does a delay in the body of urea, creatinine and other products of nitrogen metabolism begin and their levels increase in blood serum. Some nephrologists believe that only from this moment can we talk about the development of chronic renal failure in patients. Extending the concept of chronic renal failure to earlier phases of renal disease is inappropriate [Ermolenko V. M., 1982].

There is still no clear understanding of the nature of the substances that cause uremia. Creatinine and urea do not cause uremic intoxication in animal experiments. An increase in the concentration of potassium ions in the blood is toxic, since hyperkalemia leads to heart rhythm disturbances. It is believed that uremic toxins are a large group of medium-molecular substances (molecular weight - 500-5000 daltons); it consists of almost all polypeptides that carry out hormonal regulation in the body, vitamin B12, etc. In patients with chronic renal failure, the content of such substances is increased; as their condition improves, the number of medium molecules in the blood decreases. There are probably several substances that are uremic toxins

CRF most often develops in chronic and subacute glomerulonephritis (which accounts for 40% of patients with chronic renal failure), chronic pyelonephritis (32%), polycystic kidney amyloidosis, drug-induced interstitial nephritis, renal tuberculosis and a number of diseases in which the kidneys are involved in the pathological process secondary, but their damage is so significant that it leads to chronic renal failure. This refers to septic endocarditis, hypertension, systemic connective tissue diseases (systemic lupus erythematosus, systemic scleroderma, Goodpasture's syndrome), nephrosclerosis in diabetes mellitus, hypercortisolism, hypernephroma, hemolytic anemia, hemoblastosis (leukemia). All these diseases occur in pregnant women, and they should be kept in mind if, during examination of a pregnant woman, chronic renal failure is detected.

In some cases, it can be difficult to determine the cause of chronic renal failure in a pregnant woman if the history does not indicate one of the diseases mentioned above. First of all, suspect latent, unrecognized kidney damage, including late toxicosis that developed in the last weeks of pregnancy and childbirth. The absence of pathological symptoms during regular examination of women during pregnancy and normal urine tests before pregnancy do not exclude hidden kidney disease. Particularly “insidious” in this regard is chronic pyelonephritis, which can occur under the guise of late toxicosis in pregnant women with chronic renal failure. If a woman comes to the antenatal clinic late due to pregnancy, the discovery of arterial hypertension or isolated urinary syndrome does not make it possible to conduct a targeted comprehensive examination of the kidneys and the diagnosis remains. "nsphropathy of pregnancy"

Currently, there are pregnant women suffering from various manifestations of disseminated intravascular coagulation (DIC), which affects the kidneys with chronic renal failure of the predominantly glomerular type, when only pathogenetically adequate and effective anticoagulant therapy helps to decipher the nosology of nsphropathy.

In some cases, chronic glomerulonephritis manifests itself only as increased blood pressure with a persistently normal urine test. In this case, glomerulonephritis can only be proven by puncture biopsy of the kidneys, which is not used in our country in pregnant women. During pregnancy, chronic glomerulonephritis with chronic renal failure can be the initial manifestation of systemic lupus erythematosus.

With all of these variants of hidden renal pathology in pregnant women, the diagnostic value of analyzing their coagulogram, protein electrophoresis, lipidemia and creatinemia is great. It is important to monitor the height of blood pressure, the level and frequency of “residual” proteinuria in postpartum women suffering from moderate and severe nephropathy. In many cases, such an examination allowed us to clarify the true nature of the disease

It is possible that chronic renal failure may be asymptomatic, and then the diagnosis of this condition is an unexpected finding, but much more often there are extensive symptoms of azotemia - uremia. Clinical precursors of chronic renal failure are dry mouth, thirst, anemia, and blurred vision.

There are 3 stages of chronic renal failure:

Stage I - preclinical (latent) renal failure - is characterized by increased fatigue, dyspepsia, nocturia, headaches, increased blood pressure, and sometimes anemia. Indicators of nitrogen metabolism (the content of creatinine, urea, residual nitrogen) are normal, but during functional tests for dilution and concentration of urine, during the Zimptsky test (ipoisoaenuria), inferior activity of the nephrons is noted. This stage lasts for many years.

Stage II - compensated renal failure - is characterized by an increase in the content of nitrogenous waste in the blood (urea concentration - above 8.3 mmol/l, creatinine - above 200 µmol/l), electrolyte disturbances (potassium content more than 5.6 mmol/l, hypersodium is detected -mia, hypermagnesemia, hypocalcemia, hypochloremia). The glomerular filtration rate of the kidneys becomes less than 50 ml/microwave. Normochromic anemia with low reticulosis (about 3%) is noted. In blood tests of 73 patients, one can detect a decrease in the number of platelets due to their consumption in the process of disseminated intravascular coagulation, leukocytosis with a shift to the left to myelocytes, toxic granularity of neutrophils, increased ESR Diuresis is 1 liter or slightly more. The duration of this stage usually does not exceed 1 year.

Stage III - decompensated renal failure - is characterized by the appearance of life-threatening signs of the disease: severe heart failure, uncontrolled high arterial hypertension, pulmonary edema, cerebral edema, uremic pericarditis, uremic coma.

Hypostsnuria, especially in the presence of polyuria, is an important early criterion for chronic renal failure. Glomerular filtration decreases in parallel with the progression of nephrosclerosis, and therefore renal failure. Its absolute numbers are a criterion for establishing the severity of chronic renal failure, indications for use and dosage of drugs.

Since an increase in the content of residual nitrogen in the blood occurs when all nephrons are damaged 7g-7z, i.e., it is not an early indicator of renal failure, hypercreatininemia is not always accompanied by hyperazotemia (in terms of residual nitrogen), for example, with renal amyloidosis. A combined increase in both indicators is observed in chronic renal failure caused by glomerulonephritis or pyelonephritis. Acute renal failure is characterized by excessively high urea azotemia with relatively less hypercreatininemia; with chronic renal failure, there is an opposite ratio or increase in the content of both nitrogenous compounds

The diuresis indicator can serve as a differential diagnosis of acute and chronic renal failure. Acute renal failure begins with a decrease in the amount of urine (oligoanuria); with chronic renal failure there is a period of polyuria followed by a decrease in diuresis. The appearance of polyuria following the stage of oligoanuria indicates an acute process; no increase in daily diuresis - in favor of chronic renal failure Acute renal failure develops quickly after surgery, shock, infection, etc.; chronic - gradually. Laboratory data in acute renal failure and chronic renal failure are basically the same, but in contrast to acute renal failure, in chronic renal failure there is a tendency towards hypernatremia.

Radioisotope renography, still rarely used in pregnant women, is an early indicator of renal hypofunction, especially during its formation with still normal fluctuations in the relative density of urine and creatininemia. With developed chronic renal failure, renography loses its significance; it is not able to predict the evolution of kidney damage or the effectiveness of treatment.

In chronic renal failure, the level of alkaline reserve (bicarbonates) in plasma decreases due to the absorption of acidic metabolites, loss of sodium bicarbonate and retention of hydrogen ions. 85% of patients with chronic renal failure have metabolic acidosis.

We have not encountered pregnant women with a decompensated stage of chronic renal failure, since conception does not occur in such patients. The preclinical (latent) stage of renal failure is not so rarely diagnosed in patients with chronic pyelonephritis and chronic glomerulonephritis, with abnormalities of kidney development. Pregnancy at this stage of renal failure usually proceeds as with risk degree II (see sections “Glomerulonephritis”, “Pyelonephritis”). At the compensated stage of chronic renal failure, complications of pregnancy and childbirth for women and the fetus are frequent and severe (III degree of risk), therefore pregnancy at this stage of chronic renal failure is contraindicated. In addition, as already indicated, in such patients after childbirth, chronic renal failure progresses or develops acute renal failure. S. How et al. (1985) concluded that pregnancy in women with moderate renal failure may impair renal function, but fetal survival is higher than previously reported.

Treatment of patients with signs of chronic renal failure if they refuse an abortion or termination of pregnancy at a later date consists of creating a regimen, prescribing a diet and conducting drug therapy.

Pregnant women with chronic renal failure need to limit physical activity and should mainly stay in the hospital; they should be prescribed a diet that meets certain requirements: protein restriction along with the introduction of sufficient amino acids; high calorie content due to sufficient intake of fats and carbohydrates, consumption of sufficient quantities of vegetables and fruits, taking into account the characteristics of water and electrolyte disorders. The main feature of the diet is protein restriction. Outside of pregnancy, this recommendation is to constantly consume 50-60 and even 25 g of protein per day. A woman who remains pregnant, in the interests of the child, cannot be on such a diet and should receive up to 80-100 g of protein per day, not only from plant proteins (potatoes, legumes), but also from animals (meat, cottage cheese). Deliberate violation of the most important principle of diet does not contribute to the elimination of azotemia, and this, in particular, worsens the prognosis of kidney disease after childbirth. Fats and carbohydrates are not limited. Patients can consume vegetables and fruits, juices, bread, and cereals depending on their appetite. Patients should receive no more than 5 g of salt. If there is a tendency to acidosis and hypernatremia (in the absence of hyperkalemia), it is advisable to increase the amount of potassium-containing foods (apricots, walnuts, fruit juices) in the diet.

If the excretory function of the kidneys is preserved, it is useful to increase the amount of fluid consumed to 2 liters through compotes, juices, and mineral waters

Drug treatment should be carried out under mandatory monitoring of blood electrolytes. To alkalize the plasma and compensate for sodium losses, a 5% sodium bicarbonate solution (300-500 ml), a 5-20% glucose solution (300-500 ml) should be administered; for persistent vomiting - 3% sodium chloride solution (200-300 ml) or isotonic sodium chloride solution. For hypocalcemia, use 10% calcium gluconate solution (50 ml/day intramuscularly). The administration of glucose and insulin is indicated for hyperkalemia and severe liver dysfunction.

Lespenefril 10 ml 2 times a day intravenously or 10 ml 3 times a day orally, neocompensan (100 ml intravenously), hemodez (400 ml intravenously) can be used. Anabolic hormones are contraindicated for pregnant women. To stimulate diuresis, a 10-20% solution of glucose with insulin and 500 ml mannitol are administered intravenously or furosemide.

Washing the stomach and intestines with a 2% solution of sodium bicarbonate is performed in case of nausea and vomiting in order to remove nitrogenous waste from the digestive tract. This procedure is performed on an empty stomach, it can be repeated 2-4 times before meals. Microenemas with a weak solution of sodium bicarbonate with soda, hypertonic sodium chloride solution help quite well.

In addition to the indicated drug therapy, treatment of arterial hypertension is continued. There is no need to strive to reduce blood pressure to normal levels, since in this case renal blood flow decreases and kidney activity deteriorates. It is enough to maintain the pressure at 150/100 mm rg. Art. (20.0-13.3 kPa). This pressure slightly impairs kidney function, but can affect the uteroplacental circulation and fetal development. The desire to improve uteroplacental blood flow by normalizing blood pressure can lead to the progression of uremia. For the treatment of arterial hypertension, all drugs used in obstetrics can be used, except magnesium sulfate, so as not to increase the hypermagnesemia characteristic of chronic renal failure.

Cardiac glycosides are prescribed with caution, since their elimination from the body is slow and they can cause glycoside intoxication. In case of severe hypokalemia, cardiac glycosides are contraindicated.

To combat anemia, iron and cobalt supplements are used (preferably parenterally). If there is a sharp decrease in hemoglobin content, transfusions of red blood cells or freshly citrated blood are indicated. You should not strive to increase the hemoglobin content exceeding 90 g/l. Frequent blood transfusions contribute to the suppression of hematopoiesis, so they should be done once a week while using calcium supplements and desensitizing agents (diprazine, suprastin, etc.).

Among the hemostatic agents for major bleeding, in addition to calcium and vitamin K preparations, a fibrinolysis inhibitor is used - aminocaproic acid (300 ml of a 10% solution intravenously or orally 2 g 4-6 times a day).

Anticoagulants are contraindicated even in the initial stages of chronic renal failure.

Antibacterial drugs can be used in normal or reduced doses. Penicillin, oxacillin, erythromycin are used in full dose; ampicillin, methicillin - in half; kanamycin, monmycin, colimycin, polymyxin are contraindicated due to their nephrotoxicity. Gentamicin and cephalosporins are used only in extreme cases, reducing the dose by 50-70% of the usual one. If there is a risk of hyperkalemia, in particular with oligoanuria, crystalline penicillin should not be administered due to its high potassium content

Conservative therapy is effective for moderately severe renal failure.

In more severe cases, hemodialysis treatment must be used. Hemodialysis for chronic renal failure is indicated in the terminal stage, when threatening hyperkalemia (more than 7 mmol/l), acidosis (pH less than 7.28) develops, nitrogenous wastes in the blood are very high (urea - 50 mmol/l, creatinine - 1400 µmol/ l).

In pregnant women, chronic renal failure is not so severe, so hemodialysis is used only for acute renal failure.

Pregnant women with early stages of chronic renal failure should be protected from pregnancy by using intrauterine contraceptives

As shown by us [Shekhtman M M, Trutko N S, Kurbapova M. X., 1985 | intrauterine contraceptives in women with chronic glomerulonephritis and chronic pyelonephritis do not cause exacerbation of the disease, infectious processes in the genitals and hemorrhagic complications.

In other words, during large serial observations, a certain proportion of pregnant women developed severe acute renal failure. But to date, the number of cases of acute renal failure in pregnant women has decreased significantly. Currently, only 1 in 20,000 pregnant women develops AKI. This shift, associated with the liberalization of abortion rules and improvement of the obstetric and gynecological care system, unfortunately, is observed only in industrialized countries. In other countries, up to 25% of patients undergoing dialysis procedures at centers are pregnant women with acute renal failure, and acute renal failure during pregnancy continues to be a significant cause of mortality in pregnant women and fetal death.

The probability of developing acute renal failure during pregnancy has two maximums. The first occurs in the early stages of pregnancy (13-18 weeks). It is during this period that the majority of cases of acute renal failure due to septic abortion occur. The second maximum occurs at the end of pregnancy, from 35 weeks before birth. In this period, acute renal failure is usually a consequence of preeclampsia and uterine bleeding, especially with placental abruptions.

Causes of acute renal failure during pregnancy

The cause of acute renal failure during pregnancy can be any pathology that leads to renal failure in all groups of the population, for example, ATN. In the early stages of pregnancy, tubular necrosis is most often a consequence of the effect of extrarenal pathologies on the kidneys, for example, uncontrollable vomiting of pregnant women or septic abortion. At a later stage, acute renal failure can be a consequence of various less common diseases. Mild or moderate preeclampsia rarely causes kidney failure because pregnant women maintain the same level of kidney function (or nearly the same) as non-pregnant women. But there is a form of preeclampsia, the so-called HELLP syndrome (hemolysis + increased activity of liver enzymes in the blood + thrombocytopenia), which almost always causes significant impairment of kidney function, especially if it is not treated promptly and correctly.

Thrombotic microangiopathy

The difficulty of differential diagnosis of acute renal failure during pregnancy lies in the fact that in late pregnancy, acute renal failure is usually aggravated by microangiopathic hemolytic anemia and thrombocytopenia. It should be noted that pregnancy is generally considered a risk factor for the development of TTP and HUS. However, it is still unclear whether the pathogenesis of TTP and HUS in pregnant women differs from the same pathologies in non-pregnant women. TTP and HUS are quite rare in pregnant women, but they must always be differentiated from the much more common disorder, HELLP syndrome. Correct differential diagnosis of these conditions is very important for the choice of treatment methods and prognosis of the outcome, although these pathologies have much in common both in the clinical picture and in the nature of changes in laboratory parameters. However, differences do exist, especially in the time of first onset of disease and in laboratory testing. Thus, with TTP, the activity of the protease that breaks down von Willebrand factor is usually reduced in the blood. HELLP syndrome, being a form of preeclampsia, most often develops in the third trimester of pregnancy and very rarely in the first days after birth. TTP usually occurs earlier, and many cases occur in the second trimester (although it can also develop in the third trimester). HUS is most often diagnosed after childbirth, although sometimes its first clinical signs can be observed before.

Preeclampsia is much more common than TTP or HUS. This pathology is usually preceded by hypertension and proteinuria. However, renal failure in preeclampsia is quite rare. Exceptions are cases of very severe preeclampsia, complicated by bleeding, hemodynamic instability, or severe disseminated intravascular coagulation (DIC). Preeclampsia sometimes develops in the early postpartum period, and if accompanied by severe thrombocytopenia, it is almost impossible to differentiate from HUS. But preeclampsia often goes away without any treatment, while the condition of patients with HUS only sometimes improves slightly.

Unlike TTP and HUS, preeclampsia can be complicated by a mild form of disseminated intravascular coagulation with an increase in parameters such as prothrombin time and partial thromboplastin time. Another symptom characteristic only of preeclampsia (including HELLP syndrome) and absent in HUS or TTP is a significant increase in the activity of liver enzymes in the patient’s blood. Fever is more common in TTP and less common in patients with preeclampsia or HUS. The distinctive features of the GUS are the following circumstances:

HUS most often develops in the postpartum period;
It is HUS that causes the most severe degree of acute renal failure.

Preeclampsia (HELLP syndrome) after childbirth is accompanied only by supportive care. More aggressive treatments are rarely needed. The presence of TTP or HUS in a pregnant woman requires blood plasma infusions or even exchange transfusions and other therapeutic techniques that are used to treat these pathologies in non-pregnant women. It should be noted that the effectiveness of these techniques in the treatment of TTP and HUS in pregnant women has not been specifically studied.

Bilateral renal cortical necrosis

Bilateral renal cortical necrosis can be a consequence of placental abruption or rupture, as well as a consequence of other gynecological disorders accompanied by severe bleeding (for example, uterine perforation). The immediate causes of the disease in such situations are primary disseminated intravascular coagulation and severe renal ischemia. The patient develops oliguria or anuria, hematuria and flank pain. Ultrasound or CT may reveal hypoechoic areas of reduced density in the renal cortex. In most cases, patients require dialysis procedures. But in 20-40% of cases of the disease, kidney function is then partially restored.

Acute pyelonephritis

In some pregnant women, the development of acute renal failure is associated with pyelonephritis.

Acute fatty liver infiltration during pregnancy

Acute fatty infiltration of the liver during pregnancy (fatty infiltration of hepatocytes without inflammation or necrosis) is a rare complication of pregnancy, usually developing against the background of severe azotemia. Patients suffering from this complication experience anorexia and abdominal pain in the third trimester of pregnancy. Signs of preeclampsia (hypertension, proteinuria) are rare. Laboratory testing reveals an increase in the activity of liver enzymes in the blood, hypoglycemia, hypofibrinogenemia and an increase in partial prothrombin time. Induction of labor is indicated. The condition of most patients improves significantly after childbirth.

Urinary tract obstruction

During pregnancy, an expansion of the urine collection system occurs, which usually does not lead to impaired renal function. But sometimes complications occur. For example, if there are large fibroids in the uterus, which increase even more during pregnancy, urinary tract obstruction may develop. In some rare cases, kidney stones may cause this obstruction. The diagnosis of obstruction is made based on ultrasound data. Sometimes stones leave the urinary tract on their own, but in some cases cystoscopy and ureteral stenting are required to remove the stone fragment and eliminate the obstruction, especially if there is a risk of developing sepsis or if the patient has a single kidney.

Treatment of acute renal failure during pregnancy

Treatment of acute renal failure during pregnancy differs little from the treatment of this pathology in other patients. But there are still some features that you should pay attention to. Since occult uterine bleeding and undetected blood loss may occur shortly before birth, obvious blood loss should be replaced immediately. To prevent the development of acute tubular or cortical necrosis, it is even better to adhere to the tactics of some redundancy during blood transfusions. To replace renal function in pregnant women with acute renal failure, both HD and PD can be used with the same effect. Neither local peritonitis in the pelvic area nor an enlarged uterus are contraindications for PD. This dialysis method is slower than HD and is better suited for pregnant women. Since urea, creatinine and other toxic metabolites can cross the placenta during uremia, dialysis procedures in pregnant women should begin as early as possible, ensuring that the level of urea nitrogen in their blood does not exceed 50 mg/100 ml. In pregnant women, the benefits of early prophylactic initiation of renal function replacement, evident even in non-pregnant women, are of particular importance. But removing large volumes of fluid from the body during pregnancy should be avoided, since the result may be undesirable hemodynamic changes, in particular deterioration of the blood supply to the uterus and placenta and even premature birth. Some obstetricians and perinatologists recommend monitoring the condition of the fetus during dialysis procedures, especially in mid- and late pregnancy. Finally, doctors should be wary of dehydration in newborns - if the mother has uremia, the newborn may begin to have excessively active diuresis caused by urea accumulated in its blood.