Can a girl get pregnant with kidney failure? Acute renal failure during pregnancy: causes, treatment, symptoms, signs. Symptoms of kidney disease

08.08.2020

During pregnancy, a woman's body is subjected to additional stress. Absolutely all internal organs of the expectant mother work in an enhanced mode. But wise nature has thought of everything in such a way that the body copes with the task. True, there are times when it fails. Today we will talk about such an important organ as the kidney.

Why during pregnancy the kidneys work in an enhanced mode?

Because, in addition to their permanent tasks, they perform new ones: now there is a need to additionally process and remove the waste products of the fetus, which enter the woman's blood through. Now the amount released increases and averages 1200-1600 ml per day. At the same time, under the influence of the hormone a, the tone of the bladder decreases, and this can lead to stagnation of urine. As a result, the process of infection is facilitated, which leads to diseases. For example, pyelonephritis. Sometimes pregnancy provokes a "sleeping" disease, and it manifests itself.

Kidney disease - is pregnancy impossible?

Unfortunately, there are situations in which pregnancy is truly impossible. But this is determined only by a doctor and only after a thorough examination. That is why, before planning a child, to exclude pathology. With some kidney diseases, pregnancy is possible, but only after proper and timely treatment. Nevertheless, it happens that the doctor diagnoses such changes in the function of this organ, which do not allow either to bear or give birth to a baby. For example, pregnancy is contraindicated in women who have pyelonephritis accompanied by high blood pressure or renal failure.

Most Common Kidney Diseases During Pregnancy

The most common inflammatory diseases in pregnant women are asymptomatic bacteriuria and pyelonephritis.

The diagnosis of asymptomatic bacteriuria is made when a large number of bacteria are found in the urine (100,000 microbial cells per 1 milliliter of urine). At the same time, the woman does not experience any discomfort at all and does not notice any symptoms of a urinary tract infection. The disease is determined by blood and urine tests. Asymptomatic bacteriuria is dangerous because in 40% of cases, acute pyelonephritis develops on its background.

Many of the women know firsthand what cystitis is. This disease is a consequence of a variety of pathological conditions of the urinary tract and genitals. It can be the first manifestation of pyelonephritis or other urological diseases. Cystitis has obvious signs: frequent and painful urination, accompanied by cutting pains, discomfort in the suprapubic region, which increases as the bladder fills. Sometimes (at first) these symptoms are absent. In most cases, there is an increase in body temperature up to 37.5 degrees.

Cystitis is treated with antibiotic tablets. The average course of treatment is a week.

Pyelonephritis in pregnant women can first declare itself during the gestation of a baby. In this case, they talk about "pyelonephritis of pregnant women" or, as it is also called "gestational pyelonephritis". Most often it manifests itself in the second half of pregnancy. If the disease has already manifested itself earlier, even before the onset of pregnancy, then with its development it often reminds of itself with a vengeance. Such women are at high risk, since this threatens miscarriage, occurrence, intrauterine infection and fetal malnutrition. The most terrible complication of pregnancy with pyelonephritis is acute renal failure. In this state, the kidneys partially or even completely stop their work.

In order to correctly treat pyelonephritis during pregnancy, it is necessary to identify the pathogen.

Treatment of all kidney diseases is done in order to help the woman, but at the same time, not to harm the baby. If a woman experiences pain in the kidneys during pregnancy, she urgently needs a consultation with a urologist and obstetrician-gynecologist.

Especially for- Olga Pavlova

The kidney is a paired organ in the excretory system, primarily involved in the filtration of harmful substances in the urine. Renal failure during pregnancy can develop due to an increase in the size of the female reproductive organs. Enlarged organs can transmit the ureters, kidney tissue, or arteries, which interferes with kidney function, but these are not the only causes of the disease. If the kidneys fail, there are violations in the filtration and excretion of urine, followed by intoxication of the body. Renal failure during pregnancy requires immediate medical attention.

Pregnancy and chronic renal failure

Pregnancy with chronic renal failure is rather difficult. The frequency of birth complications is observed in comparison with the indicator in women without the disease. Complications can cause premature birth. There is a need for a cesarean section, intensive care for newborns. However, thanks to the development of medicine, 9 out of 10 pregnant women have the opportunity to carry and give birth to a child normally. The examinations were carried out in women with a moderate indicator of pathology.

With a severe form of the disease, pregnancy and childbirth have less chance of a successful outcome. If pregnancy with renal failure is accompanied by increased pressure in the hollow organs, vessels or body cavities, the risk of miscarriage, stillbirth, fetal death inside the womb, premature birth, large blood loss during childbirth, and impaired development in the newborn increases.

Acute renal failure, the reasons for its development

All causes leading to impaired renal function can be divided into renal and extrarenal.

In acute renal failure, there is an increased amount of urea, uric acid in the body. These chemical components destroy the body and pose a threat to the life of mother and child. The development of acute renal failure often occurs in the first or last trimester. The main causes of the development of the disease are associated with other disorders in the body.

abortion in non-sterile conditions;
postpartum bleeding;
cervical cancer;
uterine cancer;
ovarian cancer;
late termination of pregnancy;
drug poisoning during pregnancy;
toxicosis during pregnancy;
pyelonephritis before pregnancy;
blood transfusion with another Rh factor;
injury;
a strong increase in body weight;
cystitis;
stones in the kidneys;
thrush;
long stay of a dead fetus in the uterus.

Forms of acute renal failure

The course of the disease depends on the form of renal failure.

There are the following types of surge arresters:

prerenal form;
renal form;
postrenal form.

The prerenal form occurs due to impaired circulation in the kidneys. If the patient is assisted within 2 hours, the full functioning of the kidneys is quickly resumed. The renal form develops due to damage to organ cells and their dysfunction. Damage can provoke surgery, antibiotics, heavy metal poisoning. Prompt treatment can partially or completely reverse the further destruction of kidney cells. The postrenal form develops due to diseases that block the urinary ducts, such as stones. The disease causes lower back pain, possibly the development of infections or the transition to the prerenal or renal form of the disease.

Symptoms of the disease in chronic and acute renal failure

List of dangerous symptoms:

complete cessation of urine excretion;
decrease in the daily flow of urine;
pulling pain in the lower back and kidney area;
dark coffee-colored urine;
urine with blood pigments;
increased amount of protein in the urine;
vomit;
shock state;
increased body temperature;
increased blood pressure;
high concentration of potassium and nitrogen in the blood;
muscle weakness;
violation of heart rhythms;
pallor of the skin and possible yellowness of the mucous membranes;
increased thirst and dry mouth;
strong urine odor;
increased acidity of blood and urine.

In acute renal failure, a pregnant woman should be observed by a gynecologist.

With the above symptoms, you should immediately contact your gynecologist. Severe kidney failure can be fatal for both the mother and the baby. With timely treatment, kidney function can be fully restored and pregnancy preserved. If you do not contact a specialist in time, new symptoms appear, such as bloody feces, numbness of the limbs, convulsions.

The course of the disease and possible complications

Even a healthy pregnancy increases the stress on all organs and systems, including the kidneys. During pregnancy with renal failure, the entire excretory system and other organs are overstrained due to the intoxication of the body with toxic products that have not been filtered out by the kidneys. Complications are possible:

the formation of blood clots in the capillaries of the kidneys;
chronic blood pressure;
swelling due to kidney damage;
the development of anemia;
intrauterine oxygen starvation;
chronic renal failure;
kidney coma;
sepsis;
death if the disease was not subject to treatment;
infectious diseases in the genitourinary system.

Diagnosis of the disease

Based on the data of clinical and biochemical blood and urine tests, the doctor makes a diagnosis.

To make a diagnosis, the patient must pass a general blood test, a general urine test, a biochemical blood test and a microbiological urine test. Additionally, you will need to undergo an ultrasound examination of the bladder. For a complete examination, it is recommended to undergo magnetic resonance imaging.

Keywords

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

annotation scientific article on clinical medicine, the 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 intact renal function, is accompanied by an increased frequency of obstetric and perinatal complications compared to population indicators, such as the addition of preeclampsia, premature birth, the need for surgical delivery, and intensive care for newborns. The article presents its own data on complications and outcomes of pregnancy in 156 women with various stages. chronic kidney disease(CKD). Of these, 87 patients were with stage I CKD, 29 with stage II CKD and 40 with stage III, IV, V CKD, combined into the diagnosis “ chronic renal failure"(CRF). For the first time in Russia, the authors summarized the unique experience of pregnancy management in CRF, 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 CRF (preeclampsia, urinary tract infections, placental 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 frequency of pre-eclampsia, placental insufficiency, premature birth, operative delivery by cesarean section, and the state of children at birth. On the basis of a large clinical material, the probability of a favorable pregnancy outcome in patients with CRF with stable renal function and in the absence of severe arterial hypertension during pregnancy has been proven: for a child in 87%, for a mother in 90% (maintaining the same stage of CKD). The risk of a persistent decrease in renal function during pregnancy and in the postpartum period in women with CRF increases with CKD stage IV 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 with planning pregnancy and intensive joint management of patients by an obstetrician-gynecologist and nephrologist from early 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 / gynecologist and a nephrologist from early weeks of gestation onwards.

Modern medicine manages to cope with most acute kidney diseases and inhibit the progression of most chronic ones. Unfortunately, until now about 40% of renal pathologies are complicated by the development of chronic renal failure (CRF).

This term means the death or replacement by connective tissue of part of the structural units of the kidneys (nephrons) and irreversible impairment of kidney function to cleanse the blood from nitrogenous toxins, produce erythropoietin, which is responsible for the formation of red blood elements, remove excess water and salts, and reabsorb electrolytes.

The consequence of chronic renal failure is a disorder of water, electrolyte, nitrogenous, acid-base balance, which leads to irreversible changes in the state of health and often becomes the cause of death in terminal chronic renal failure. The diagnosis is made in case of violations registered for three months or longer.

Today, CRF is also called chronic kidney disease (CKD). This term emphasizes the potential for the development of severe forms of renal failure even at the initial stages of the process, when the glomerular filtration rate (GFR) has not yet been reduced. This allows for more careful treatment of patients with asymptomatic forms of renal failure and improve their prognosis.

CRF criteria

The diagnosis of chronic renal failure is made if a patient has one of two types of renal impairment for 3 months or more:

Kidney damage with violation of their structure and function, which are determined by laboratory or instrumental diagnostic methods. However, GFR may decrease or remain normal.
There is a decrease in GFR of less than 60 ml per minute with or without kidney damage. This rate of filtration rate corresponds to the death of about half of the kidney nephrons.

What leads to chronic renal failure

Almost any chronic kidney disease without treatment can sooner or later lead to nephrosclerosis with kidney failure to function normally. That is, without timely therapy, such an outcome of any renal disease as chronic renal failure is just a matter of time. However, cardiovascular pathologies, endocrine diseases, systemic diseases can lead to failure of renal functions.

Kidney disease: chronic glomerulonephritis, chronic tubulointerstitial nephritis, renal tuberculosis, hydronephrosis, polycystic kidney disease, nephrolithiasis.
Pathology of the urinary tract: urolithiasis, urethral strictures.
Cardiovascular disease: arterial hypertension, atherosclerosis, incl. angiosclerosis of the renal vessels.
Endocrine pathologies: diabetes.
Systemic diseases: renal amyloidosis,.

How does chronic renal failure develop

The process of replacing the affected kidney glomeruli with scar tissue is simultaneously accompanied by functional compensatory changes in the remaining ones. Therefore, chronic renal failure develops gradually with the passage of several stages in its course. The main cause of pathological changes in the body is a decrease in the rate of blood filtration in the glomerulus. The glomerular filtration rate is normally 100-120 ml per minute. An indirect indicator by which one can judge GFR is blood creatinine.

The first stage of chronic renal failure - initial

At the same time, the glomerular filtration rate remains at the level of 90 ml per minute (variant of the norm). There is confirmed kidney damage.

Second stage

It suggests kidney damage with a slight decrease in GFR in the range of 89-60. For the elderly in the absence of structural damage to the kidneys, such indicators are considered the norm.

Third stage

At the third moderate stage, GFR drops to 60-30 ml per minute. At the same time, the process taking place in the kidneys is often hidden from view. There is no bright clinic. An increase in the volume of excreted urine, a moderate decrease in the number of erythrocytes and hemoglobin (anemia) and associated weakness, lethargy, decreased performance, pallor of the skin and mucous membranes, brittle nails, hair loss, dry skin, decreased appetite are possible. In about half of patients, an increase in blood pressure appears (mainly diastolic, i.e. lower).

Fourth stage

It is called conservative, since it can be restrained by drugs and, like the first, does not require blood purification by apparatus methods (hemodialysis). In this case, glomerular filtration is kept at the level of 15-29 ml per minute. Clinical signs of renal failure appear: severe weakness, decline in working capacity against the background of anemia. The volume of excreted urine increases, significant urination at night with frequent nocturnal urges (nocturia). About half of the patients suffer from high blood pressure.

Fifth stage

The fifth stage of renal failure is called terminal, i.e. ultimate. With a decrease in glomerular filtration below 15 ml per minute, the amount of urine excreted (oliguria) drops until it is completely absent at the end of the state (anuria). All signs of poisoning of the body with nitrogenous slags (uremia) appear against the background of violations of water-electrolyte balance, damage to all organs and systems (primarily, the nervous system, heart muscle). With this development of events, the patient's life directly depends on blood dialysis (purification of it bypassing non-working kidneys). Patients die without hemodialysis or kidney transplantation.

Chronic kidney failure symptoms

The appearance of patients

The appearance does not suffer until the stage when glomerular filtration is significantly reduced.

Due to anemia, pallor appears, due to water-electrolyte disturbances, dry skin.
As the process progresses, yellowness of the skin and mucous membranes appears, a decrease in their elasticity.
Spontaneous bleeding and bruising may occur.
Combing occurs.
Characterized by the so-called renal edema with puffiness of the face up to common anasarca type.
Muscles also lose their tone, become flabby, due to which fatigue increases and the ability to work of patients decreases.

Nervous System Disorders

This is manifested by lethargy, disturbed sleep at night and daytime sleepiness. Decreased memory, learning ability. As chronic renal failure increases, severe lethargy and disorders of the ability to remember and think appear.

Disturbances in the peripheral part of the nervous system affect the chilliness of the limbs, tingling sensations, crawling creeps. Later, movement disorders in the arms and legs join.

Urinary function

She first suffers from the type of polyuria (increased urine volume) with a predominance of nocturnal urination. Further, chronic renal failure develops by reducing the volume of urine and the development of edematous syndrome up to the complete absence of excretion.

Water-salt balance

salt imbalance is manifested by increased thirst, dry mouth
weakness, darkening in the eyes when standing up suddenly (due to sodium loss)
excess potassium explains muscle paralysis
breathing disorders
a decrease in heartbeats, arrhythmias, intracardiac blockages up to cardiac arrest.

Against the background of an increase in the production of parathyroid glands of parathyroid hormone, a high level of phosphorus and a low level of calcium in the blood appear. This leads to softening of bones, spontaneous fractures, itching of the skin.

Nitrogen imbalance

They cause an increase in blood creatinine, uric acid and urea, as a result of:

with GFR less than 40 ml per minute, enterocolitis develops (damage to the small and large intestine with pain, bloating, frequent loose stools)
ammoniacal odor
secondary articular lesions of the type of gout.

The cardiovascular system

firstly, it reacts with an increase in blood pressure
secondly, lesions of the heart (muscles -, pericardial sac - pericarditis)
dull pains in the heart, heart rhythm disturbances, shortness of breath, swelling in the legs, enlarged liver appear.
with an unfavorable course of myocarditis, the patient may die against the background of acute heart failure.
pericarditis can occur with the accumulation of fluid in the pericardial sac or the loss of uric acid crystals in it, which, in addition to pain and expansion of the borders of the heart, when listening to the chest gives a characteristic ("funeral") pericardial rubbing noise.

Hematopoiesis

Against the background of a deficiency in the production of erythropoietin by the kidneys, hematopoiesis slows down. The result is anemia, manifested very early on by weakness, lethargy, and decreased performance.

Pulmonary complications

characteristic of the late stages of chronic renal failure. This is the uremic lung - interstitial edema and bacterial inflammation of the lung against the background of a drop in immune defenses.

Digestive system

She reacts with decreased appetite, nausea, vomiting, inflammation of the oral mucosa and salivary glands. With uremia, erosive and ulcerative defects of the stomach and intestines appear, fraught with bleeding. Acute hepatitis also becomes a frequent companion of uremia.

Renal failure during pregnancy

Even a physiologically proceeding pregnancy significantly increases the burden on the kidneys. In Chronic Kidney Disease, pregnancy aggravates the course of the pathology and can contribute to its rapid progression. This is due to the fact that:

during pregnancy, increased renal blood flow stimulates the overstrain of the renal glomeruli and the death of some of them,
deterioration of the conditions for the reabsorption of salts in the kidney tubules leads to the loss of high volumes of protein, which is toxic to the renal tissue,
increased work of the blood coagulation system contributes to the formation of small blood clots in the capillaries of the kidneys,
worsening of the course of arterial hypertension during pregnancy contributes to glomerular necrosis.

The worse the filtration in the kidneys and the higher the creatinine figure, the more unfavorable the conditions for the onset of pregnancy and its bearing. A pregnant woman with chronic renal failure and her fetus face a number of pregnancy complications:

Arterial hypertension
Nephrotic syndrome with edema
Preeclampsia and eclampsia
Severe anemia
and fetal hypoxia
Delays and malformations of the fetus
and premature birth
Infectious diseases of the urinary system of a pregnant woman

Nephrologists and obstetricians-gynecologists are involved in solving the issue of the feasibility of pregnancy in each specific patient with chronic renal failure. At the same time, it is necessary to assess the risks for the patient and the fetus and correlate them with the risks that the progression of chronic renal failure every year reduces the likelihood of a new pregnancy and its successful resolution.

Treatment methods

The beginning of the fight against CRF is always the regulation of diet and water-salt balance.

Patients are advised to eat with a restriction of protein intake within 60 grams per day, the predominant use of vegetable proteins. With the progression of chronic renal failure to stages 3-5, protein is limited to 40-30 g per day. At the same time, they slightly increase the proportion of animal proteins, giving preference to beef, eggs and lean fish. The egg and potato diet is popular.
At the same time, the consumption of products containing phosphorus (legumes, mushrooms, milk, white bread, nuts, cocoa, rice) is limited.
An excess of potassium requires reducing the consumption of black bread, potatoes, bananas, dates, raisins, parsley, figs).
Patients have to get by with a drinking regimen at the level of 2-2.5 liters per day (including soup and drinking pills) in the presence of severe edema or intractable arterial hypertension.
It is helpful to keep a food diary, which makes it easier to keep track of protein and micronutrients in food.
Sometimes specialized mixtures are introduced into the diet, enriched with fats and containing a fixed amount of soy proteins and balanced in trace elements.
Along with the diet, patients may be shown an amino acid substitute - Ketosteril, which is usually added with a GFR of less than 25 ml per minute.
A low-protein diet is not indicated for exhaustion, infectious complications of chronic renal failure, uncontrolled arterial hypertension, with GFR less than 5 ml per minute, increased protein breakdown, after surgery, severe nephrotic syndrome, terminal uremia with lesions of the heart and nervous system, poor diet tolerance.
Salt is not limited to patients without severe arterial hypertension and edema. In the presence of these syndromes, salt is limited to 3-5 grams per day.

Enterosorbents

They make it possible to somewhat reduce the severity of uremia due to binding in the intestine and excretion of nitrogenous toxins. This works in the early stages of chronic renal failure with relative safety of glomerular filtration. Used Polyphepan, Enterodez, Enterosgel, Activated carbon,.

Treating anemia

To stop anemia, erythropoietin is administered, which stimulates the production of red blood cells. Uncontrolled arterial hypertension becomes a limitation to its use. Since against the background of treatment with erythropoietin, iron deficiency may occur (especially in menstruating women), therapy is supplemented with oral iron preparations (Sorbifer durules, Maltofer, etc. see).

Blood clotting disorder

Correction of blood clotting disorders is performed by Clopidogrel. Tiklopedin, Aspirin.

Arterial hypertension treatment

Drugs for the treatment of arterial hypertension: ACE inhibitors (Ramipril, Enalapril, Lisinopril) and sartans (Valsartan, Candesartan, Losartan, Eprozartan, Telmisartan), as well as Moxonidine, Felodipine, Diltiazem. in combinations with saluretics (Indapamide, Arifon, Furosemide, Bumetanide).

Disorders of phosphorus and calcium metabolism

It is stopped with calcium carbonate, which prevents the absorption of phosphorus. Lack of calcium - synthetic preparations of vitamin D.

Correction of water-electrolyte disturbances

is carried out in the same way as the treatment of acute renal failure. The main thing is to get rid of the patient from dehydration against the background of restriction in the diet of water and sodium, as well as the elimination of blood acidification, which is fraught with severe shortness of breath and weakness. Solutions with bicarbonates and citrates, sodium bicarbonate are introduced. A 5% glucose solution and Trisamine are also used.

Secondary infections in chronic renal failure

This requires the prescription of antibiotics, antivirals, or antifungal drugs.

Hemodialysis

With a critical decrease in glomerular filtration, the blood is purified from nitrogen metabolism substances by hemodialysis, when the slags pass into the dialysis solution through the membrane. The most commonly used apparatus is the "artificial kidney", less often peritoneal dialysis is performed, when the solution is poured into the abdominal cavity, and the peritoneum plays the role of the membrane. Hemodialysis for chronic renal failure is carried out in a chronic mode. For this, patients travel for several hours a day to a specialized center or hospital. At the same time, it is important to timely prepare an arterio-venous shunt, which is prepared with a GFR of 30-15 ml per minute. From the moment the GFR falls less than 15 ml, dialysis is started in children and patients with diabetes mellitus; if the GFR is less than 10 ml per minute, dialysis is performed in other patients. In addition, indications for hemodialysis will be:

Severe intoxication with nitrogenous products: nausea, vomiting, enterocolitis, unstable blood pressure.
Treatment-resistant edema and electrolyte disturbances. Edema of the brain or pulmonary edema.
Expressed acidification of the blood.

Contraindications to hemodialysis:

coagulation disorders
persistent severe hypotension
tumors with metastases
decompensation of cardiovascular diseases
active infectious inflammation
mental illness.

Kidney transplant

It is the ultimate solution to chronic kidney disease. After that, the patient has to use cytostatics and hormones for life. There are cases of repeated transplants, if for some reason the transplant is rejected. Renal failure during pregnancy against the background of a transplanted kidney is not an indication for interrupting gestation. pregnancy can be carried out before the required period and is resolved, as a rule, by caesarean section at 35-37 weeks.

Thus, Chronic Kidney Disease, which has replaced the concept of “chronic kidney failure” today, allows doctors to more timely see the problem (often when there are no external symptoms) and respond by starting therapy. Adequate treatment can prolong or even save the patient's life, improve his prognosis and quality of life.

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 renal excretory function.

CRF is a relatively common syndrome. It is a consequence of excretory and endocrine hypofunction of the kidneys. The most important indicators of CRF sSlow is the delay in the body of creatish, its clearance (the coefficient of purification, 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 chronic renal failure predominantly of the glomerular type, which is characterized primarily by hypercreatininemia, and chronic renal failure of the tubular type, which manifests itself at first by hypostenuria.

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 (corresponds to a decrease in the number of nephrons to 30%), a delay in the body of urea, creatinine and other products of nitrogen metabolism and an increase in their level in serum. Some nephrologists believe that only from this moment can we talk about the development of chronic renal failure in patients. The extension of the concept of chronic renal failure to the earlier phases of renal disease is inappropriate [Ermolenko VM, 1982].

Until now, there is no clear idea of the nature of the substances that cause uremia Creatinine and urea do not cause uremic intoxication in an experiment on animals. An increase in the concentration of potassium ions in the blood is toxic, since hyperkalemia leads to a violation of the heart rhythm. It is believed that uremic toxins are a large group of medium-molecular substances (molecular weight - 500-5000 daltons); it is composed of almost all polypeptides that regulate hormonal regulation in the body, vitamin B12 and others.

CRF most often develops in chronic and subacute glomerulonephritis (which accounts for 40% of patients with CRF), chronic pyelonephritis (32%), polycystic and renal amyloidosis, drug interstitial nephritis, renal tuberculosis and a number of diseases in which the kidneys are involved in the pathological process secondary, but their defeat 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 are found in pregnant women, and they should be borne in mind if chronic renal failure is detected during the examination of a pregnant woman.

In some cases, it is difficult for a pregnant woman to determine the cause of CRF if there is no history of one of the diseases mentioned above. First of all, suspect a latent, unrecognized kidney damage, including with late toxicosis, which developed in the last weeks of pregnancy and childbirth. Chronic pyelonephritis, which can proceed under the guise of late toxicosis of pregnant women with chronic renal failure, is especially "insidious" in this regard. "Nsphropathy of pregnant women"

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

In some cases, chronic glomerulonephritis manifests itself only as high blood pressure with consistently normal urine analysis. In this case, glomerulonephritis can be proved only by a 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 these variants of latent renal pathology in pregnant women, the diagnostic value of the analysis of their co-agulogram, protein electrophoresis, indicators of lipidemia and creatinemia is important. It is important to monitor the height of blood pressure, the level and frequency of "residual" proteinuria in puerperas with moderate and severe nephropathy. Such an examination in many cases allowed us to clarify the true nature of the disease.

Perhaps the asymptomatic course of chronic renal failure, and then the diagnosis of this condition is an unexpected find, but more often there is an extensive symptomatology of azotemia - uremia. Clinical precursors of CRF are dry mouth, thirst, anemia, and visual impairment.

There are 3 stages of chronic renal failure:

Stage I - preclinical (latent) renal failure - characterized by increased fatigue, dyspepsia, nocturia, headaches, increased blood pressure, and sometimes anemia. The indicators of nitrogen metabolism (the content of creatinine, urea, residual nitrogen) are normal, but with functional tests for dilution and concentration of urine, with the Zimpptsky test (] hypoisoaenuria), the nephrons' activity is not complete. This stage lasts for many years.

Stage II - compensated renal failure - characterized by an increase in the content of nitrogenous toxins in the blood (urea concentration - above 8.3 mmol / L, creatinine - above 200 μmol / L), electrolyte disturbances (potassium content is more than 5.6 mmol / L, hyper sodium -miya, hypermagnesemia, hypocalcemia, hypochloremia). Kidney cell filtration becomes less than 50 ml / micron. There is normochromic anemia with low reticulosis (about 3%) In the blood tests of 73 patients, it is possible to find a decrease in the number of platelets due to their consumption during intravascular disseminated blood coagulation, leukocytosis with a shift to the left to myelocytes, toxic granularity of neutrophils Diuresis, increased ESR is 1 liter or 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 symptoms of the patient: severe heart failure, uncontrolled high arterial hypertension, pulmonary edema, cerebral edema, uremic pericarditis, uremic coma.

Hypostnuria, especially in the presence of polyuria, is an important early criterion for CRF. Glomerular filtration decreases in parallel with the progression of nephrosclerosis, and hence 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, i.e., it is not an early indicator of renal failure, hypercreatininemia is not always accompanied by hyperazotemia (for 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 an increase in the content of both nitrogenous compounds

The indicator of diuresis 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 urine output. The appearance of polyuria following the stage of oligoanuria is evidence in favor of an acute process; no increase in daily urine output - 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 CRF are basically the same, but in contrast to acute renal failure in CRF, there is a tendency to hypernatremia.

Radioisotope renography, which is 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 meaning; she is unable to predict the evolution of kidney damage or the effectiveness of treatment.

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

We did not have to meet pregnant women with decompensated stage of chronic renal failure, since conception in such patients does not occur. The preclinical (latent) stage of renal failure is diagnosed not so rarely in patients with chronic pyelonephritis and chronic glomerulonephritis, with abnormalities in the development of the kidneys. Pregnancy at this stage of renal failure usually proceeds as at the II degree of risk (see sections "Glomerulonephritis", "Pyelonephritis"). With a compensated stage of chronic renal failure, complications of pregnancy and childbirth are frequent and severe for women and the fetus (III degree of risk), therefore, pregnancy at this stage of CRF 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 mild renal failure may impair renal function, but that fetal survival is higher than previously reported.

Treatment of patients with signs of chronic renal failure, in the event that they have refused an abortion or termination of pregnancy at a later date, consists in creating a regimen, prescribing a diet and conducting drug therapy.

Pregnant women with chronic renal failure need to limit physical activity, should mainly be in the hospital; they should be given a diet that meets certain requirements: protein restriction along with the introduction of sufficient amino acids; high calorie content due to the sufficient introduction of fats and carbohydrates, the consumption of a sufficient amount of vegetables and fruits, taking into account the peculiarities of water-electrolyte disturbances. The main feature of the diet is protein restriction. Outside of pregnancy, this recommendation is to consistently consume 50-60 and even 25 g of protein per day. A woman who maintains a pregnancy, in the interests of a child, cannot be on such a diet and must receive up to 80-100 g of protein per day, and not only from plant proteins (potatoes, legumes), but also from animals (meat, cottage cheese). A deliberate violation of the most important principle of the diet does not contribute to the elimination of azotemia, and this, in particular, worsens the prognosis of the course of kidney disease after childbirth. Fats and carbohydrates are not limited. Patients can eat vegetables and fruits, juices, bread, cereals depending on their appetite. Patients should receive no more than 5 g of salt. With 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.

With the preserved excretory function of the kidneys, it is useful to increase the amount of fluid consumed up to 2 liters due to compotes, juices, mineral waters

Drug treatment should be carried out under the obligatory control of blood electrolytes. To alkalize the plasma and replace sodium losses, 5% sodium bicarbonate solution (300-500 ml), 5-20% glucose solution (300-500 ml) should be injected; with persistent vomiting - 3% sodium chloride solution (200-300 ml) or isotonic sodium chloride solution In case of hypocalcemia, a 10% solution of calcium gluconate (50 ml / day intramuscularly) is used. The appointment of glucose and insulin is indicated for hyperkalemia and severe liver dysfunctions.

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

Lavage of the stomach and intestines with 2% sodium bicarbonate solution is performed with nausea, vomiting in order to remove nitrogenous toxins from the digestive tract. This procedure is performed on an empty stomach, you can do it again 2-4 times before meals. Microclysters with a weak solution of sodium bicarbonate with soda, a hypertonic solution of sodium chloride help a lot.

In addition to the indicated drug therapy, the treatment of arterial hypertension is continued. It is not necessary to strive to reduce the pressure to normal values, since in this case the renal blood flow decreases and the activity of the kidneys worsens. It is enough to maintain the pressure at the level of 150/100 mm rg. Art. (20.0-13.3 kPa). Such pressure slightly impairs kidney function, but can affect 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 for magnesium sulfate, so as not to increase the hypermagnesemia characteristic of CRF

Cardiac glycosides are prescribed with caution, since the time for their elimination from the body is slowed down and they can cause glycosidic intoxication. With severe hypokalemia, cardiac glycosides are contraindicated.

To combat anemia, iron and cobalt preparations are used (preferably parenterally). With a sharp decrease in the hemoglobin content, transfusions of erythrocyte mass or freshly citrated blood are indicated. One should not strive for an increase in the hemoglobin content exceeding 90 g / l. Frequent blood transfusions contribute to the inhibition of hematopoiesis, so they should be done once a week against the background of the use of calcium preparations and desensitizing agents (diprazine, su-prastin, etc.).

Of the hemostatic agents for large bleeding, in addition to calcium and vitamin K preparations, a fibrinolysis inhibitor is used - aminocaproic acid (intravenous drip of 300 ml of 10% solution 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 regular or reduced doses. Penicillin, oxacillin, erythromycin are used in full dose; ampicillin, methicillin - in half; kanamycin, monmicin, colimycin, polymyxin are contraindicated due to their nephrotoxicity. They resort to gentamicin and cephalosporins only in extreme cases, reducing the dose by 50-70% of the usual. With the threat of hyperkalemia, in particular with oligoanuria, crystalline penicillin should not be administered due to its high potassium content

Conservative therapy is effective in moderate renal failure.

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

In pregnant women, chronic renal failure is not so significantly pronounced, therefore hemodialysis is used only in acute renal failure.

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

As shown by us [Shekhtman MM, Trutko NS, Kurbapova M. Kh., 1985 | intrauterine contraceptives in women with chronic glomerulonephritis and chronic pyelonephritis do not exacerbate the disease, infectious processes in the genitals and hemorrhagic complications.