Drug Induced Acute Renal Failure in Pregnancy –Management.

Drug Induced Acute Renal Failure in Pregnancy –Management.

The goal of treatment is to identify the drug which may cause acute renal failure and treat any reversible causes of the kidney failure such as use of kidney-toxic medications.

                Treatment also focuses on preventing excess accumulation of fluids and wastes, while allowing the kidneys to heal and gradually resume their normal function. Hospitalization is required for treatment and monitoring.

It is dividing into

A.      Medical Management

B.      Obstetrical Management

Medical Management

Reversible Prerenal acute Renal Failure

a.       Establish and correct the underlying cause of ARF

b.      Hypovolemia if present restore blood volume as rapidly as possible depending on what is lost

c.       Optimize systemic hemodynamic. Measurement of central venous pressure or pulmonary wedge pressure as adjunct to clinical examination may aid in determining the rate of administration of fluid.

d.      Correct metabolic acidosis- restoration of blood volume will correct acidosis by restoring kidney function, isotonic sodium bicarbonate may be used

e.      Recent trials do not support use of low dose dopamine in severely ill patients at risk of ARF.

Re-established Acute Renal Failure

Emergency Resuscitation

a.       Hyperkalemia should be corrected immediately

b.      Circulating blood volume should be optimized to ensure adequate renal perfusion

c.       Severe acidosis can be ameliorated with isotonic sodium bicarbonate.

Fluid and Electrolyte Balance

a.       Daily fluid intake should be equal to urine output, plus additional 500 ml to cover insensible losses

b.      Measurement of fluid intake and output should be weighed daily

c.       Since sodium, potassium are retained hence intake of these substances should be restricted.

Protein and Energy intake

It’s important to give energy and nitrogen to hyper catabolic patients in adequate.

Infection Control

Regular clinical examination and microbiological investigation should be done to reduce any complication.

Drugs

NSAID and ACE inhibitors may prolong ARF hence temporary withdrawal should be considered.

Hemodialysis

Dialysis may be used to remove excess waste and fluids. This often makes the person feel better and may make the kidney failure easier to control. Dialysis may not be necessary for all people, but is frequently lifesaving, particularly if serum potassium is dangerously high.

Hemofiltration

Used to remove excess of body water along with electrolytes across high flux semi permeable membrane.

Peritoneal Dialysis

This can correct electrolyte imbalance and equally effective as hemodialysis.

Supportive Therapy

a.       To control infection if indicated

b.      Vitamins

c.       Blood transfusion

d.      Control of hyperphoshatemia

Phase of Diuresis

a.       Intake and output chart should be maintained and serum electrolytes are monitored

b.      To control fluid balance

c.       To control electrolyte balance

d.      Supplementation of salt-5 gm sodium chloride for each liter of urine passed.

Phase of Recovery

Clinical improvement along with increased amount of urine with more and more concentrating power is evidenced with diurnal variation of specific gravity between 1002-1020 were observed. Diet and food as per patient’s desire.

Obstetrical Management

Prerenal-any condition leads to hypovolemis, hypotension, volume contraction and low cardiac output.

Early Pregnancy

a.       Severe dehydration due to Hyperamesis gravidarum and acute pyelonephritis = replacement of fluid along with electrolye, and monitoring of kidney function

b.      Severe infection due to septic abortion = antibiotic metrogyl, laparotomy if indicated

c.       Acute and massive blood loss due to abortion, ectopic pregnancy and hydatidiform mole = surgical management

Mid Pregnancy

a.       APH-abruptio placenta, placenta previa = immediate surgical intervention

b.      Pre-eclampsia and eclampsia and HELLP syndrome =antihypertensive, anticonvulsion along with other medical management.

Late pregnancy and labor

a.       Severe uterine infection due to intrauterine death of fetus, or chorioamnonities = antibiotic

b.      PPH = medical and surgical management

c.       Traumatic delivery- surgical management.

Immediate postpartum

a.       Puerperal sepsis due to chorioamnonitis- treated by antibiotics

b.      Drug sensitivity due to ergot treatment of hypersensitivity

c.       Consumptive coagulopathy- by fresh blood transfusion, plasma or platelet transfusion heparin, etc.

Prognosis

Although acute renal failure is potentially life-threatening and may require intensive treatment, it usually reverses within several weeks to a few months after the underlying cause been treated.

                Conservative management when failed, may progress to chronic renal failure and/or end-stage renal disease. Death is most common when the cause of kidney failure is related to surgery or trauma or when it occurs in people with coexisting heart disease, lung disease or recent stroke. Old age, infection, loss of blood from the GI tract, and progression of the kidney failure also increase the risk of death.