The new @RenalAssoc Pregnancy and Renal Disease Guideline (chaired by @DrKateWiles) is a veritable goldmine of practical pearls and clinical wisdoms, as well as some new or updated practice-changing recommendations. Here come a few of my take-homes... #renalSCE #meded #CKD
@RenalAssoc @DrKateWiles First the pre-conception ACEi/ARB advice has been clarified. Quite clear now that continuing ACEi up until the point of missed-period or positive test in strong-indication patient (eg IgA disease) is sound strategy. Lack of data means @renalassoc advise avoiding ARB #meded
@RenalAssoc @DrKateWiles This guideline clears up the slightly wishy-washy advice about breastfeeding on immunosuppressant drugs in the @RenalAssoc transplant guideline. Prednisolone, Tacrolimus, cyclosporin, azathioprine = all recommended safe to breastfeed. #meded
@RenalAssoc @DrKateWiles Although overall safety of rituximab in pregnancy is unclear, if using then aim to do so EARLY (T1) as actively transported across placenta in T2 and T3 risking neonatal B cell depletion #meded
@RenalAssoc @DrKateWiles Although progesterone-only contraceptive methods are considered safe and effective in patient with CKD (eg Mirena coil, Implanon or POP) they should be avoided in patients with history of breast cancer and risk/benefit considered if eg known BRAC mutation #meded
@RenalAssoc @DrKateWiles Women previously treated with cyclophosphamide meet criteria for fertility service referral after ONE (not two) years of unprotected intercourse due to their higher risk of infertility #meded (the pearls just keep on coming...)
@RenalAssoc @DrKateWiles In women with CKD undergoing IVF, @RenalAssoc recommend single embryo transfer (and not iatrogenic twinning), as the poor materno-foetal outcomes of multiple pregnancy outweigh reduced success of implantation #MedEd
@RenalAssoc @DrKateWiles Pre-natal genetic diagnosis is approved by the HFEA in AD and ARPKD, Alport, Fabry and cystinosis, and thus specialist clinical genetics centre referral should be considered in patients where this may be relevant #meded
@RenalAssoc @DrKateWiles Serum creatinine should be used for assessing and monitoring renal function in pregnancy (not eGFR), as the latter is not valid and prone to be misleading. 95th centile value for creatinine T2 pregnancy is 59 micromole/l #MedEd
@RenalAssoc @DrKateWiles Women with T1 exposure to foetotoxic medications should be referred to a specialist foetal medicine unit. Similarly FMU referral is indicated for a positive Trisomy screen due to the increased false positive rate in CKD #MedEd
@RenalAssoc @DrKateWiles Specific advice from @RenalAssoc to offer aspirin (75-150mg/day) to kidney donors to reduce risk of pre-eclampsia, in addition to the more general advice to offer this to all women with CKD #MedEd
@RenalAssoc @DrKateWiles Blood pressure targets and thresholds have changed. New @RenalAssoc guidance is a target BP or <135/85 in pregnant patients with CKD, and not stopping (or reducing) unless BP <110/70 or symptoms of low BP #MedEd
@RenalAssoc @DrKateWiles Some clear guidance around kidney biopsies in pregnancy. Bleeding risk goes up later in pregnancy, so if histology will genuinely change management, then aim should be to do this before 22 weeks #MedEd
@RenalAssoc @DrKateWiles Renal transplant should not be considered a contra-indication to vaginal delivery; vertical skin incision before horizontal uterine incision may help reduce risk of allograft injury (although data is lacking) #MedEd
@RenalAssoc @DrKateWiles Some clear advice now from @RenalAssoc to titrate dialysis dose in pregnant women on HD to achieve a pre-dialysis urea of <12.5mmol/l (higher ureas are inversely associated with IUGR and adverse outcomes) #meded
@RenalAssoc @DrKateWiles Also a new recommendation that patients on PD convert to HD if they become pregnant, unless strong extenuating cirumstances (eg lack of vascular access) #MedEd
@RenalAssoc @DrKateWiles Target weight should be reassessed weekly in pregnant women on HD, factoring in 300g/wk weight gain during T2, and 300-500kg/wk weight gain in T3 #MedEd
@RenalAssoc @DrKateWiles Last one, promised - @RenalAssoc recommend dialysis be initiated at maternal ureas of 17-20mmol/l assuming that risks of preterm delivery outweigh those of dialysis initiation (relevant if pregnancy is approaching 34 weeks) #MedEd
@RenalAssoc @DrKateWiles And I could go on. It is literally a never-ending resource of practical and helpful guidance for woman with CKD who is either pregnant or considering pregnancy. A must-read for all UK nephrologist. Thanks @DrKateWiles and team! #renalSCE #MedEd
