Acute renal failure in pregnant women. Chronic renal failure and pregnancy Chronic renal failure and pregnancy

Kidney failure is a serious pathology that can affect the general condition of a woman and the development of the fetus. As a rule, 20% of women with a similar diagnosis experience pregnancy complications after the second trimester and in postpartum recovery. Pregnancy does not aggravate the pathogenesis of infectious renal diseases, however, complications can occur with uncontrolled hypertension. In this article we will tell you how kidney failure during pregnancy affects the body of the woman and the fetus. Let's look at the symptoms and treatment methods.

Characteristics of the disease

Kidney failure has negative impact on the body, namely, with such a diagnosis, the ability of the kidneys to produce and excrete urine normally is lost, as well as to remove excess and toxic substances from the body. Depending on the form of the pathology, this ability may be lost or partially impaired, which entails complex and negative consequences for health. Violation of nitrogen, water and other important internal metabolisms leads to the failure of vital systems, and as a result, the patient’s health deteriorates significantly. In medicine, this pathology is divided into two types:

• Acute form- manifests itself as a result of severe burns, fractures, hemorrhagic shock, toxic effects of poisons and harmful substances, disturbances in the passage of the ureteric canals, infectious diseases of the kidneys, pyelonephritis and nephritis. A sharp deterioration in kidney function, resulting in complete or partial disruption of nitrogen metabolism.
• Chronic form- manifests itself as a result of previous kidney diseases and nephron death. The pathology is characterized by deterioration in functionality, performance and general condition of the entire renal system and health.

The diagnosis of chronic renal failure is established provided that the patient has had the following kidney and system disorders for more than three months:

• damage to an organ with impaired functionality, structure, deviation is determined by diagnosis;
• the filtration rate decreases to a level of 60 ml per 1 minute in combination with and without kidneys.

Forms of acute kidney pathology

• perenal form- formed as a result of circulatory disorders in the kidneys; with timely assistance to the patient, kidney function is restored and begins to work as usual;
• renal form- formed as a result of damage to organ cells and their dysfunction; antibiotics and heavy metal intoxication can provoke their damage;
• post-acute form- is formed as a result various diseases blocking the urinary system or stones.

Causes of chronic renal failure

Chronic renal failure is a rather complex form of kidney disease, which requires constant treatment and a number of preventive measures to prevent negative consequences. If you ignore the recommendations of your doctor and do not follow therapy, chronic renal failure develops into kidney failure and nephrosclerosis. The reasons why chronic renal failure occurs:

• kidney pathology: chronic glomerulonephritis and pyelonephritis, kidney tuberculosis, polycystic kidney disease, organ cancer and nephrlithiasis;
• diseases of the urinary tract:
• urethral stricture, urolithiasis;
• cardiovascular diseases: atherosclerosis, arterial hypertension, angiosclerosis of renal vessels;
• endocrine diseases: diabetes, thyroid problems;
• systemic pathologies: hemorrhagic vasculitis, renal amyloidosis.

Symptoms of kidney disease

The stage of renal failure, symptoms and general condition directly depend on the nature and morphology of the disease. The first symptoms of the disease appear in anemia, the chemical content of nitrogen and potassium substances, as well as an increase or decrease in the volume of urination per day. The symptoms of the pathology are as follows:

• Change appearance due to impaired glomerular filtration, due to anemia, the skin color changes, it becomes pale and painful, dryness appears, and elasticity decreases. Spontaneous hemorrhages and itching may also appear. Due to impaired renal function, swelling, puffiness appears, muscle mass loses its elasticity and becomes flabby;
• Violation nervous system. This symptom manifests itself in sleep disturbances, the appearance of apathy, memory deterioration, and the formation of limb disorders;
• A violation of the urinary system manifests itself in the form of a sharp increase in the volume of urine, over time the volume decreases and may disappear altogether;
• An imbalance in the water-salt balance in the body manifests itself in constant thirst, dry mouth, breathing is impaired, arrhythmia appears, the heartbeat quickens, the patient feels unwell and weak;
• An increased level of parathyroid hormone production, as a result of which the level of phosphorus prevails over calcium in the blood, where softening of bone tissue and the formation of fractures occurs;
• Violation of the nitrogen balance leads to the formation of an ammonia taste in the mouth, affecting the small and large intestines with severe pain attacks;
• A disorder of the cardiovascular system manifests itself in the form of an increase in blood pressure, damage to the heart, heart rate, shortness of breath, swelling of the extremities, the liver increases in size, acute heart failure and death may occur;
• A disorder of the blood system manifests itself in insufficient production of erythropoietin by the kidneys.

Disturbance of the digestive system manifests itself in the form of decreased appetite, attacks of nausea and severe vomiting, and inflammation of the salivary glands.

Pregnancy and kidney pathology

Kidney failure and pregnancy significantly increases the load on a woman’s entire renal system. In chronic renal failure, pregnancy significantly worsens the morphology of the disease and entails its progression. Causes of complications:

• during pregnancy, strong blood flow increases and stimulates the tension of the renal tangles, some of which die;
• the process of normal absorption of salt by the renal tubules is disrupted, as a result of which the protein breaks down in large volumes, and its particles are toxic to the kidney tissue;
• due to increased work of the blood coagulation system, small blood clots are formed in the renal capillaries;
• Arterial hypertension increases, resulting in kidney necrosis.

During the period of deterioration of the filtration process by the kidneys, the level of creatinine increases, which complicates the conditions and course of pregnancy, and the gestation of the fetus becomes unfavorable. Complications of chronic renal failure for a pregnant woman:

• nephrotic syndrome with the formation of severe swelling;
• arterial hypertension;
• complex form of anemia;
• delay and defects in fetal development;
• inability to bear a fetus, premature birth;
• infectious pathologies of the urinary system.

Treatment method for disease during pregnancy

To prevent the formation of negative consequences and eliminate complications of renal failure in pregnant women, do the following:

• eliminate ectopic bleeding and hemodynamic disorders;
• with a normal gestational age, rapid delivery is performed to avoid stillbirth and fetal growth arrest;
• during the period of perenal acute renal failure, the intravascular volume of fluid should be restored, restoration is carried out by introducing a zotonic solution of sodium chloride;
• treatment of acute tubular necrosis is aimed at eliminating ischemia and infection, maintaining fluid balance and restoring blood supply to the organ;
• the early stage of cortical necrosis is eliminated with anticoagulant therapy; if there is no result, hemodialysis is used;
• During the development of obstructive acute renal failure, detoxification and antibacterial therapy is performed.

Kidney failure and pregnancy are a complex process that requires constant monitoring and supervision by specialists. With timely observation by specialists and implementation of recommendations, a positive result in bearing a fetus is possible.

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 significant reason mortality of pregnant women and death of fetuses.

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. During 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 is that later During 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. Distinctive features 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 maintenance therapy. 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.

Among extragenital pathologies in pregnant women, kidney and urinary tract diseases occupy second place after diseases of the cardiovascular system and pose a danger to both the mother and the fetus. Preeclampsia develops early and is severe, frequent spontaneous miscarriages, premature birth, premature abruption of a normally located placenta, intrauterine infection of the fetus, its malnutrition and chronic hypoxia, birth of immature premature babies, stillbirth. In turn, pregnancy can contribute to the emergence of renal pathology, or an exacerbation of chronic kidney diseases that occur latently before pregnancy.

Pregnancy predisposes to kidney disease due to disturbances in urodynamics, caused by changes in topographic-anatomical relationships as the size of the uterus increases, and the effect of progesterone on urinary tract receptors. Hypotension and expansion of the collecting system and ureters are observed (the capacity of the pelvis together with the ureters, instead of 3-4 ml before pregnancy, reaches 20-40, and sometimes 70 ml, in the second half). In addition, in the second half of pregnancy the uterus deviates to the right (rotating in the same direction) and thereby puts more pressure on the area of ​​the right kidney, which can apparently explain the greater frequency of right-sided lesions of the urinary system. A decrease in the tone and amplitude of ureteral contractions begins after the third month of pregnancy and reaches a maximum by the eighth month. Restoration of tone begins in the last month of pregnancy and continues during the third month of the postpartum period. A decrease in the tone of the upper urinary tract and stagnation of urine in them during pregnancy leads to increased pressure in the renal pelvis - this is important in the development of pyelonephritis. A significant role in the development of renal pathology during pregnancy is played by:

Weakening of the ligamentous apparatus of the kidneys, contributing to pathological mobility of the kidneys;

Increased frequency of vesicoureteral reflux;

Increased secretion of estrogen and progesterone, glucocorticoids, placental hormones - chorionic gonadotropin and chorionic somatomammotropin.

The infection enters the urinary tract through the ascending route (from the bladder), descending – lymphogenous (from the intestines, especially with constipation), hematogenous (with various infectious diseases). Pathogens: Escherichia coli, gram-negative ecterobacteria, Pseudomonas aeruginosa, Proteus, Enterococcus, Staphylococcus aureus, Streptococcus, Candida type fungi.

It should be noted that frequently occurring clinical forms are pyelonephritis, hydronephrosis, asymptomatic bacteriouria. Less commonly - glomerulonephritis, hip joints of the kidneys, urolithiasis, anomalies of the urinary tract.

PYELONEPHRITIS

Pyelonephritis- this is the most frequent illness during pregnancy (from 6 to 12%), in which the concentration ability of the kidneys suffers. Pyelonephritis has an adverse effect on the course of pregnancy and the condition of the fetus. The most common complication is late gestosis, miscarriage, intrauterine infection of the fetus. Serious complications include acute renal failure, septicemia, septicopyemia, and bacterial shock. Pregnant women pyelonephritis is considered a high-risk group. Most often, pyelonephritis is detected during pregnancy - 12-15 weeks, 24-29 weeks, 32-34 weeks, 39-40 weeks, and in the postpartum period on days 2-5 and 10-12. Pyelonephritis in pregnant women may occur for the first time, or may appear (exacerbate) if the woman had it before pregnancy. Pregnant women with pyelonephritis should be hospitalized with each exacerbation of the disease, with signs of late gestosis, deterioration of the fetus's condition (hypoxia, malnutrition.)

Pathogens pyelonephritis are gram-negative microorganisms of the intestinal group, Pseudomonas aeruginosa, Proteus, fungi such as Candida, staphylococci. The infection spreads hematogenously from the source of inflammation - pharyngeal tonsils, teeth, genitals, gall bladder. An ascending route is also possible - from the urethra and bladder.

CLINIC

There are acute, chronic, latent and gestational pyelonephritis.

Acute pyelonephritis in pregnant and postpartum women it is manifested by the following symptoms: sudden onset of the disease, temperature (39-40° C), pain in the lumbar region, general malaise, headache, shaking chills followed by profuse sweat, adynamia, pain throughout the body, intoxication. Increased pain in the lower back is explained by the transition of the inflammatory process to the kidney capsule and perinephric tissue. Pain along the ureter, difficulty urinating, forced position on the side with the lower limbs adducted. Pasternatsky's symptom is positive. Edema is not typical, diuresis is sufficient, blood pressure is normal. The urine sediment contains leukocytes, erythrocytes, various casts and epithelial cells. The appearance of cylinders indicates damage to the renal parenchyma. Urinalysis according to Nechiporenko - normal ratio of leukocytes and erythrocytes is 2:1 (in 1 ml urine 4000 leukocytes and 2000 erythrocytes(the norm is indicated for pregnant women)). With pyelonephritis, the number of leukocytes in the urine may be normal, but leukocyturia is observed in Nechiporenko tests. Bacteriuria is an important symptom of pyelonephritis. In urine, according to Zimnitsky, there is a decrease in relative density and a violation of the ratio of daytime and nighttime diuresis towards the latter, which indicates a decrease in the concentrating ability of the kidneys. The hemogram of pregnant women suffering from pyelonephritis is leukocytosis, an increase in band forms, a decrease in hemoglobin. Blood biochemistry - changes in the total amount of protein and protein fractions due to a decrease in albumin.

Chronic pyelonephritis - outside of exacerbation there is dull pain in the lower back, no urine a large number of protein, slightly increased number of leukocytes. During pregnancy it can worsen, sometimes twice, three times, with each exacerbation the woman must be hospitalized.

It is important to know the 3 degrees of risk of pregnancy and childbirth in patients with pyelonephritis:

Grade 1 includes patients with uncomplicated pyelonephritis that occurred during pregnancy;

To 2nd degree - patients with chronic pyelonephritis existing before pregnancy;

To the 3rd degree - women with pyelonephritis and hypertension or anemia, pyelonephritis of a single kidney.

Patients with risk levels 1 and 2 may be allowed to prolong pregnancy with constant dynamic monitoring by a therapist or nephrologist. For patients with risk level 3, pregnancy is contraindicated.

Differential diagnosis- with acute appendicitis, acute cholecystitis, renal and hepatic colic, general infectious diseases. The difficulty is presented by the differential diagnosis with nephropathy and hypertension. Severe proteinuria, changes in the fundus of the eye - angioretinopathy, neuroretinopathy, hemorrhages and retinal edema speak for the addition of preeclampsia, which significantly worsens the patient's condition.

TREATMENT

Treatment of pyelonephritis in pregnant and postpartum women is carried out according to the general principles of therapy for the inflammatory process of the kidneys under the control of urine culture and sensitivity to antibiotics. The complex of therapeutic measures includes the following: prescribing a complete fortified diet, knee-elbow position for 10-15 minutes several times a day and sleeping on the healthy side, diathermy of the perinephric area, drinking mineral waters(Essentuki No. 20). Antibiotics for 8-10 days, nevigramon - 2 capsules 4 times a day for 4 days, then 1 capsule 4 times a day for 10 days. From the 2nd trimester - 5-NOK, 2 tablets. 4 times a day for 4 days, then 1 tablet 4 times a day for 10 days; furagin 0.1 4 times a day for 4 days and 0.1 3 times a day for 10 days. Detoxification therapy - hemodez, rheopolyglucin, albumin, protein. For the treatment of intrauterine fetal hypotrophy - 5 ml of Trental intrauterine with 500 ml of 5% glucose solution. Antispasmodics - baralgin 5 ml IM, Avisan 0.05 3 times a day; suprastin or diphenhydramine 1 tablet. Once a day, diuretics - herbs, bearberry, kidney tea.

If therapy does not produce results, catheterization of the ureters is performed. Delivery is carried out through the natural birth canal. Caesarean section in conditions of an infected organism is extremely undesirable and is performed according to strictly obstetric indications. In 10% of cases, early delivery is performed when pyelonephritis is combined with severe gestosis and in the absence of effect from the therapy. In the postpartum period, treatment of pyelonephritis is continued for 10 days. The woman is discharged from the maternity hospital under the supervision of a urologist.

GLOMERULONEPHRITIS

Glomerulonephritis pregnant women - from 0.1% to 9%. This is an infectious-allergic disease leading to immunocomplex damage to the glomeruli of the kidneys. The causative agent is hemolytic streptococcus. Most often, this disease occurs after a sore throat or flu.

CLINIC

Lower back pain, headaches, decreased performance, frequent urination. The main symptom during pregnancy is swelling on the face under the eyes, on lower limbs, anterior abdominal wall. Increased blood pressure, retinoangiopathy. In the urine there is protein, red blood cells, white blood cells, casts. In urine tests according to Nechiporenko, the number of erythrocytes prevails over the number of leukocytes. In severe cases, there is an increase in creatinine, urea, and residual nitrogen. Anemia.

Differential diagnosis - with cardiovascular diseases, pyelonephritis, late gestosis. Glomerulonephritis is not an absolute indication for termination of pregnancy. However, we must remember that the prognosis for the mother and fetus can be very serious. Late gestosis develops early and is very difficult. 11% of women experience spontaneous miscarriages, 29% have premature birth. Possible complications such as encephalopathy, heart failure, renal failure, which can lead to the death of a woman, malnutrition and hypoxia intrauterine fetus, until his antenatal death. The death rate of premature babies after childbirth is high. Bleeding is possible during pregnancy, childbirth and the postpartum period, as thrombocytopenia and changes in the coagulation link, characteristic of phase 1 of DIC, develop. In the future, there may be severe hypocoagulation of the type 2nd and even 3rd phases of DIC syndrome.

In the early stages of pregnancy, it is necessary to examine and decide on the possibility of continuing the pregnancy. Acute glomerulonephritis is an indication for termination of pregnancy. After acute glomerulonephritis, pregnancy is possible no earlier than 3-5 years later.

Chronic glomerulonephritis in the acute stage with severe hypertension and azotemia is a contraindication for prolonging pregnancy.

Management and treatment of women with glomerulonephritis is carried out jointly by an obstetrician-gynecologist and a nephrologist. In addition to initial hospitalization in the early stages of pregnancy, inpatient treatment is indicated at any time when the general condition worsens, signs of threatened miscarriage, late gestosis, hypoxia and fetal malnutrition.

At 36-37 weeks, planned hospitalization in the department of pathology of pregnant women is necessary to prepare for childbirth and select a method of delivery. An indication for early delivery is considered to be exacerbation of chronic glomerulonephritis, accompanied by impaired renal function (decreased daily diuresis, glomerular filtration, renal blood flow, impaired protein metabolism, increased azotemia, increased blood pressure, the addition of severe forms of late gestosis, lack of effect from the treatment). Preparation of the birth canal and generally accepted schemes for induction of labor are prescribed. During childbirth, antispasmodics, analgesics are used, and bleeding is prevented. The second stage of labor is carried out depending on the blood pressure numbers, the condition of the fetus (controlled hypotension, obstetric forceps, perineotomy). Caesarean section in pregnant women with glomerulonephritis is rarely performed, mainly for obstetric indications. In the postpartum period, if the condition worsens, the postpartum woman is transferred to a specialized hospital, and in the future she is under under the supervision of a physician or nephrologist.

TREATMENT

Treatment of acute glomerulonephritis begins with antibiotics (penicillin and its synthetic analogues), using antihypertensive drugs in combination with diuretics (adelfan, triampur, 1-2 tablets per day). For the hypertensive form of glomerulonephritis, peripheral vasodilators, ganglion blockers, and drugs that reduce the load on the heart are used (clonidine 0.000075-0.00015, 2-4 tablets per day, anaprilin 0.01 4 times a day after meals, obzidan 0.04 2-4 times a day or in the form of a 0.1% solution, 1-5 ml intramuscularly; apressin 0.01-0.025 2-4 times a day, 2% papaverine solution 2.0 ml IM, 1% dibazol solution 2-3 ml IM, aminophylline solution 2.4% - 10 ml IV; diadynamic currents, galvanization of the collar zone, ultrasound on the kidney area pulse mode; IV protein preparations: albumin 5%-10%-20% - 75-100 ml, protein 200-300 ml, dry plasma diluted 1:3, 200-100 ml 1-2 times a week, vitamins, desensitizing agents . In case of acute renal failure, one should resort, first of all, to catheterization of the ureters for diagnostic and therapeutic purposes.

URINOLOGICAL DISEASE (USD)

This pathology occurs in 0.1-0.2% of pregnant and postpartum women. The following factors play a role in the development of urolithiasis: changes in phosphorus-calcium metabolism, impaired metabolism of uric and oxalic acid, dilation of the ureters and pelvis, decreased tone, difficulty in outflow and increased concentration of urine - all this contributes to the formation of stones. Infection plays a big role. Chronic pyelonephritis is complicated by urolithiasis disease in 85% of pregnant women, in 80% pyelonephritis is associated with urolithiasis. Changes in urodynamics and hypertrophy of the ureters predispose to the advancement of stones, so the course of urolithiasis during pregnancy worsens. Often the disease is first discovered during pregnancy.

CLINIC

Clinic characterized by the classic triad - pain, hematuria, passage of stones. The attack occurs suddenly - pain in the lower back with irradiation to the groin, labia, leg, epigastrium. We differentiate with acute appendicitis, cholecystitis. Patients try to find a comfortable position - knee-elbow, on the side. In pregnant women, right-sided colic is more common. Pasternatsky's symptom is positive. Blood tests are normal, urine tests show red blood cells, white blood cells, and salt crystals. The attack leads to the threat of termination of pregnancy and premature birth. In some cases, it is necessary to carry out early delivery if the attack cannot be stopped.

DIAGNOSTICS

Diagnosis of urolithiasis during pregnancy is difficult. X-ray examination in the first half of pregnancy is unacceptable, in the second half it is undesirable, which is why it is important to recognize this disease before pregnancy. They allow the use of radioisotope renography, chromocystoscopy, catheterization of the ureters or pelvis, ultrasound scanning, and thermal imaging.

TREATMENT

Surgical treatment of urolithiasis is not routinely performed in pregnant women. Emergency surgery is performed on women with long-term unrelieved renal colic, the presence of anuria, an attack of acute pyelonephritis, and when catheterization of the pelvis failed to restore the outflow of urine.

For this purpose, to relieve an attack of renal colic, the following are used: medications: 2% solution of promedol 1.0 IM, 50% solution of analgin 2.0 ml IM, baralgin 5 ml, 2.5% solution of halidor 2.0 ml, 2% solution of papaverine, 2% solution of NO-SHPA 2 ml, 1% diphenhydramine solution, 2-2.5% pipolfen 2 ml. Cystenal 20 drops, Avisan 0.05 3 times a day. Prescribing a diet to prevent the formation of stones.

KIDNEY ANOMALIES AND PREGNANCY

Clinical forms of anomalies: kidney dystopia, double kidney, aplasia of one kidney, horseshoe kidney. All pregnant women suffering from a malformation of the uterus must have their urinary system examined to identify possible abnormalities in the development of the kidneys. Establishing a diagnosis is not very difficult thanks to intravenous urography. The issue of pregnancy management is decided depending on the type of kidney anomaly and the degree of preservation of their function. The most unfavorable form of the anomaly is considered to be polycystic kidney. It is extremely rare, but, as a rule, the function is impaired, so the issue of continuing pregnancy should be decided individually, taking into account the degree of renal dysfunction.

If there is aplasia of one kidney, the function of the second kidney should be well examined. If it is completely preserved, the pregnancy can be left. The same tactics should be used when establishing a horseshoe-shaped or double kidney in a pregnant woman. With a dystopic kidney, management of pregnancy and childbirth depends on its location. If it is located above the nameless line, i.e. in the pelvic area, independent natural childbirth is quite acceptable. If the kidney is located in the pelvis, then it can become an obstacle to normal course childbirth, or be subject to serious injury during childbirth. Therefore, the issue of managing pregnancy and childbirth is decided in advance.

ASYMPTOMIC BACTERIURIA

According to various authors, it is observed in 45 to 10% of pregnant women. This is a condition when a significant number of virulent microorganisms are found in the urine of a woman without any clinical symptoms of a urinary tract infection. Asymptomatic bacteriuria refers to those cases when 100,000 or more bacteria are found in 1 ml of urine taken through a catheter. The most common are Escherichia coli, Klebsiella, Enterobacteriaceae, and Proteus. Pregnant women with asymptomatic bacteriuria should be carefully examined to identify latent diseases of the urinary system. Against the background of asymptomatic bacteriuria, approximately 25% develop acute pyelonephritis, so it is necessary for such pregnant women to undergo timely preventive treatment with nitrofurans, sulfonamides, antibiotics, taking into account the sensitivity of the identified bacterial flora to them. Try to avoid prescription of tetracycline antibiotics and others medicines in the first 3 months of pregnancy. Antibacterial therapy aimed at eliminating asymptomatic bacteriuria reduces the incidence of pyelonephritis to 1-2%. The effectiveness of treatment is monitored by culture of urine for flora.

The kidney is a paired organ in the excretory system, primarily involved in filtering harmful substances in the urine. Kidney failure during pregnancy can develop due to an increase in the size of the female reproductive organs. Enlarged organs can put pressure on the ureters, kidney tissue or arteries, which impairs the functioning of the kidneys, but these are not the only reasons for the development of the disease. When the kidneys fail, disturbances in the filtration and excretion of urine are observed, followed by intoxication of the body. Kidney failure during pregnancy requires immediate medical attention.

Pregnancy and chronic renal failure

Pregnancy with chronic renal failure is quite difficult. The frequency of birth complications is observed in comparison with the rate in women who do not have the disease. Complications can cause premature birth. There is a need for caesarean section, carrying out 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 moderate pathology.

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

Acute renal failure, causes of its development

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

• abortion under unsterile conditions;
• postpartum hemorrhage;
• cervical cancer;
• uterine cancer;
• ovarian cancer;
• late pregnancy termination;
• poisoning during pregnancy with drugs;
• toxicosis during pregnancy;
• pyelonephritis before pregnancy;
• blood transfusion with another Rh factor;
• injury;
• severe 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 following types of surge arresters are distinguished:

• prerenal form;
• renal form;
• postrenal form.

The prerenal form occurs due to poor circulation in the kidneys. If the patient receives help within 2 hours, the full functioning of the kidneys quickly resumes. The renal form develops due to damage to organ cells and their dysfunction. Damage can be caused by surgery, antibiotics, and heavy metal poisoning. Timely treatment can partially or completely reverse further damage to kidney cells. The postrenal form develops due to diseases that block the urinary ducts, such as stones. The disease causes lower back pain, possible development of infections or 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 output;
• decrease in daily urine output;
• nagging pain in the lower back and kidney area;
• dark coffee-colored urine;
• urine with blood pigments;
• increased amount of protein in urine;
• vomit;
• state of shock;
• increased body temperature;
• increased blood pressure;
• high concentrations of potassium and nitrogen in the blood;
• muscle weakness;
• disturbance of heart rhythms;
• pale skin and possible yellowness of mucous membranes;
• increased thirst and dry mouth;
• strong smell of urine;
• increased acidity of blood and urine.

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

Course of the disease and possible complications

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

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

Diagnosis of the disease

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

Treatment methods

Kidney failure in pregnant women requires complex treatment. First of all, treatment is aimed at restoring the woman’s well-being and preserving the life of her and her child. The woman is prescribed a special diet, vitamins and immunostimulants, and possibly a blood transfusion. Depending on the stage of the disease, anabolic, antiviral and antifungal drugs may be prescribed. Surgery is possible. The chronic form of the disease is not subject to complete restoration of kidney function, however, with qualified care for the pregnant woman, childbirth proceeds normally.

Restorative nutrition

The first stage of complex treatment consists of procedures aimed at removing metabolic products from the body that the kidneys are not able to remove. The next step consists of prescribing a special diet that regulates the water-salt balance. This type of nutrition involves taking easily digestible foods. Switch to plant protein consumption and limited consumption of animal protein. It is important to limit milk, white bread, mushrooms, nuts, cocoa, and white rice in your diet. Due to excess potassium, it is important to reduce foods containing it: bananas, dates, raisins, different kinds nuts For symptoms of anemia, it is recommended to eat foods rich in iron: beets, grapes, cranberries, pomegranate, carrots, buckwheat, spinach, lentils. The patient is prescribed to drink plenty of fluids, up to 3 liters per day. For edema, it is important to reduce salt intake.

Other treatments

The patient is prescribed sorbents. Sorbent preparations bind and remove excess nitrogen from the body. Depending on the form of the disease, the patient may be prescribed various nutritional supplements and medications to eliminate the symptoms of the disease. If renal failure was caused by poisoning, the patient is prescribed procedures to cleanse and restore the blood using medications. If there is significant blood loss, the patient is given blood and plasma transfusions. If the function of urination has been completely lost, the woman’s kidneys are washed with a special solution in order to obtain a reflex to urinate. In addition to the main treatment, it is recommended to abandon any severe physical activity. Smoking and drinking alcohol are prohibited. In the acute stage, bed rest is prescribed. A woman should avoid stress and not become overcooled.

Postpartum acute renal failure

Postpartum acute renal failure can develop several days after birth or after several weeks.

The disease develops due to large blood loss, trauma, infection, and the administration of broad-spectrum medications. As the disease develops, a woman experiences an increase in body temperature, pain in the kidney area, difficulty urinating, and lack of appetite. The liver may become enlarged and abdominal pain may be felt. Acute renal failure is often accompanied by other disorders associated with dysfunction in other body systems. If additional disturbances occur in the respiratory and cardiovascular systems, death may occur.

kidney.propto.ru

At the stage of preconception preparation or from the first trimester of pregnancy, all patients took gestagen-containing drugs - dydrogesterone or micronized progesterone - to prevent primary placental insufficiency. When planning pregnancy, drugs were prescribed in the second phase of the menstrual cycle with continuation of therapy in a continuous mode from the moment positive test for pregnancy up to the 20th week of gestation with their gradual abolition over 7 days. Dydrogesterone was prescribed according to following diagram: orally 10 mg² r/day, micronized progesterone was used vaginally 200 mg/day before the 12th week of gestation, after the 12th week - orally 300 mg/day. Considering the progesterone component of these drugs, during treatment Special attention focused on the prevention of urinary tract infection (UTI) and detection of bacteriuria.

Since endothelial-platelet dysfunction is one of the pathogenetic factors in the development/progression of both preeclampsia and fetoplacental insufficiency, as well as chronic renal failure, all pregnant women received timely anticoagulant therapy. From the stage of prenatal preparation or from early dates pregnancy (in the absence of such preparation), patients were subcutaneously injected with low molecular weight heparin 1–2 times a day or they received heparin inhalations through a nebulizer of 12,500–25,000 units. 2 times a day with an interval of 12 hours. Drug doses were adjusted in accordance with hemostasiogram parameters. Anticoagulants were discontinued no later than 12 hours before delivery. Heparin therapy was resumed on the first day of the postpartum period (no earlier than 6 hours after birth) and continued for 5–6 weeks. The inhalation method of administering unfractionated heparin is more acceptable for long-term outpatient use (there is no need for strict coagulation control, the cost of unfractionated heparin is lower) and is characterized by a significantly lower number of hemostasiological and injection complications. In addition, all patients took dipyridamole, starting at 25 mg three times a day with a gradual increase in dose to 75 mg three times a day.

umedp.ru

Signs of kidney failure

Signs of kidney failure in women largely depend on the degree of dysfunction of the organ:

Initial degree – at at this stage There are no clinical symptoms, but the tissues of the organ are already experiencing pathological changes; Oliguric stage - symptoms appear and increase: the amount of urine excreted per day decreases, lethargy, lethargy, nausea, vomiting, increased heart rate, shortness of breath, cardiac arrhythmia, abdominal pain appear (the duration of this stage is up to 10 days); Polyuric stage – the patient’s condition returns to normal, the daily volume of urine increases and often corresponds to physiological indicators, however, at this stage the development of infectious and inflammatory diseases of the urinary system is possible; Rehabilitation stage – the kidneys begin to function fully and are almost completely restored. If a large number of nephrons are damaged during acute renal failure, then complete restoration of organ function is impossible.

Symptoms of kidney failure in women

The chronic form of the disease develops as a result of the progression of acute renal failure. The condition is characterized by the destruction and death of the kidneys (glomeruli, nephrons, parenchyma), as a result, the organ cannot perform its functions - this leads to disruptions in the functioning of other vital organs.

Depending on the degree of damage to the renal tissue and the severity of the patient’s condition, several stages of chronic renal failure with different symptoms are distinguished:

Hidden stage (latent) - there are no clinical manifestations of the disease, so the patient has no idea about his condition - however, with increasing physical activity, weakness, dry mouth, drowsiness, lethargy, fatigue, and increased urine output occur; Clinical stage - at this stage, clinical symptoms of intoxication of the body occur: nausea, vomiting, pale skin, lethargy, drowsiness, lethargy, a sharp decrease in the volume of urine excreted, diarrhea, the appearance of bad breath, tachycardia, cardiac arrhythmia, headaches; Stage of decompensation - to the signs of general intoxication of the body, complications are added in the form of frequent respiratory diseases, inflammatory infections of the urinary organs; Compensation stage (or terminal stage) – there is a decline in the functions of vital human organs, resulting in death. Clinically, this stage is manifested by symptoms of severe intoxication of the body, impaired functioning of all organs, unpleasant smell from the mouth, jaundice skin, development of neurological disorders.

Symptoms of kidney failure during pregnancy

During pregnancy, renal failure syndrome may develop, caused by impaired renal function as a result of compression of the ureters, renal artery or organ tissue by the growing uterus. In this case, you expectant mother The following clinical symptoms appear:

A sharp decrease in the volume of daily urine, up to complete anuria; Increased blood pressure levels; The appearance of protein in urine analysis; Swelling of the face and limbs; Nausea, vomiting; Lethargy, weakness, headaches; Signs of intoxication of the body; Paleness of the skin.

At the first appearance of such signs, you should immediately contact your gynecologist. Severe renal failure during pregnancy can have a detrimental effect on the development of the fetus in the uterus, including its antenatal death.

Treatment of kidney failure

The sooner renal failure is identified and treated, the higher the patient’s chances of a complete recovery.

The acute form of the disease is a reversible condition, for the treatment of which it is important to determine the causes of organ dysfunction. Treatment of the underlying disease and hemodialysis help restore normal kidney function.

For concomitant inflammatory diseases of the urinary organs, antibiotics and immunostimulants are prescribed.

In case of renal failure caused by severe poisoning, toxins or drugs, the patient is prescribed hemosorption and plasmapheresis. In case of acute blood loss - transfusion of blood and plasma substitutes.

In the chronic form of the pathology, it is impossible to completely restore kidney function, but it is possible to stop the development of irreversible processes and somewhat improve the patient’s quality of life. For this, the patient is prescribed regular dialysis and a special diet.

Nutrition for kidney failure should be balanced, and the products should be easily digestible. It is advisable to arrange fasting days 1-2 times a week. Fermented milk products should be present on the table every day - kefir, yogurt, low-fat cottage cheese.

In addition to the basic treatment plan drawn up by the doctor individually, the patient must strictly follow the specialist’s recommendations:

Elimination of physical activity; No stress; Quitting alcohol and smoking; Bed rest in the acute stage.

In case of chronic renal failure, after normalization of the patient's general condition, if possible, an operation to transplant a donor kidney is performed. This significantly helps improve the quality and prolong the patient's life.

Complications

With progression of symptoms and lack of timely treatment, there is a high risk of complications:

Transition of the disease into a chronic form; Uremic coma; Sepsis.

If kidney failure is not treated, the patient will quickly die.

medic-sovet.ru

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Acute renal failure is an acute disorder of the excretory function of the kidneys, most often of ischemic or toxic origin, manifested by rapidly increasing azotemia and severe water and electrolyte disturbances.

Epidemiology
The incidence of acute renal failure varies widely in different countries, on average, there are from 30 to 60 cases of acute renal failure per 1 million adult population within one year. Of these, 5-6% develop chronic renal failure, requiring constant treatment with program hemodialysis. Obstetric and gynecological causes of acute renal failure account for 15-20% of all possible etiological factors in the occurrence of this pathology. In recent years, there has been a decrease in the incidence of acute renal failure in obstetric and gynecological practice. This is associated with a decrease in the number of septic complications, bleeding, early diagnosis And complex treatment preeclampsia, improving pregnancy hygiene.

Etiology and pathogenesis
Acute renal failure is a clinical condition that always develops quickly, within a few hours or days, with bilateral damage to both kidneys or a single kidney.

In obstetric pathology, the following causes of acute renal failure are distinguished:
- not directly related to pregnancy (sepsis in infectious diseases, etc.);
- associated with pregnancy (decreased blood volume with uncontrollable vomiting of pregnant women, eclampsia, placental abruption and uterine bleeding, intrauterine fetal death and amniotic fluid embolism);
- postpartum acute renal failure, which is based on thrombotic microangiopathy with selective kidney damage.

The polyetiology of this pathology determines the presence of various pathogenetic mechanisms.

The mechanism of development of acute renal failure is based on renal ischemia. Reduced renal blood flow leads to acute tubular changes. Disruption of reabsorption processes leads to an increased supply of sodium to the macula densa and stimulates the production of renin, which causes and maintains spasm of the afferent arterioles with redistribution of renal blood flow. Shunting of blood through the juxtaglomerular system with a decrease in pressure in the glomerular afferent arterioles below 6070 mm Hg. causes cortical ischemia, induces the release of catecholamines, activates the renin-angiotensin system with the production of renin, an antidiuretic hormone. Severe ischemia of the distal tubules, which are most sensitive to hypoxia, causes necrosis of the tubular epithelium and basement membrane, up to the development of tubular necrosis. Ischemic damage to the renal tubules in acute renal failure is often aggravated by their simultaneous direct toxic damage caused by endotoxins.

Clinical picture
There are three variants of the clinical course of acute renal failure:
- acute renal failure “pure” acute renal failure.

In these patients, as a rule, obstetric care or surgery was performed in a timely manner and the level of blood loss is low. By the time of admission to a specialized hospital, the obstetric and gynecological aspect of the disease fades into the background. The clinical picture is dominated by the uremia syndrome itself, the severity of which depends on the duration of the disease;
- acute renal failure due to sepsis. The symptoms of sepsis, which usually occurs with liver damage and disseminated intravascular coagulation syndrome, are superimposed on the uremic background, mutually reinforcing the pathological manifestations;
- acute renal failure due to exogenous poisoning. To the polymorphic picture of acute renal failure and genital sepsis are added symptoms of exogenous intoxication, depending on the method of toxin administration (damage to the gastrointestinal tract, signs of toxic hepatitis, liver failure).

In the second and third options, the clinical course of acute renal failure is the most severe and the highest mortality is observed.

Diagnostics
Anamnesis
In obstetric and gynecological practice, postrenal anuria occupies a special place, early diagnosis of which allows one to avoid serious, often fatal consequences. In particular, postrenal acute renal failure can develop when both ureters are ligated, in patients with cervical, uterine or ovarian cancer when both ureters are involved in the tumor process. The clinical picture includes complaints of pain in the lumbar region. To exclude a tumor process in the pelvic cavity, bimanual vaginal and rectal examinations are performed.

The list of examinations includes:
- ultrasound examination of the bladder;

- catheterization of the bladder;

- MR survey urography;

- kidney biopsy;
- cystoscopy;

- scintigraphy.

Laboratory tests include:
- general blood analysis;

- general urine analysis;
- Rehberg test;
- Zimnitsky test;

- indicators of general hemodynamics: minute volume of blood, plasma and red blood cells, peripheral resistance to blood flow, blood flow speed.

Differential diagnosis
When examining patients with oligoanuria, it is necessary to distinguish this condition from acute urinary retention. To do this, an ultrasound examination or catheterization of the bladder is performed. With anuria, the bladder is empty. These examination methods also make it possible to diagnose bladder rupture, especially with associated trauma. In prerenal acute renal failure, the sodium and chlorine contents in the urine are reduced, and the urine creatinine/plasma creatinine ratio is increased, indicating a relatively preserved concentrating ability of the kidneys (in renal acute renal failure, the opposite ratio is observed). The excreted sodium fraction in prerenal acute renal failure is less than 1, and in renal acute renal failure it is 2.

At the final stages, a kidney biopsy is performed. It is indicated for prolonged anuria, acute renal failure of unknown etiology, suspected drug-induced acute tubulointerstitial nephritis, and acute renal failure associated with glomerulonephritis or systemic vasculitis.

Consultation with other specialists
The pregnant woman is monitored together with a urologist. Consultations with a therapist, nephrologist and surgeon are indicated.

Treatment
Goal of treatment
Normalization of kidney function, fight against severe organ complications.

Indications for hospitalization
If acute renal failure is suspected, observation and treatment are carried out only in a hospital setting.

Non-drug treatment
Following general nutritional recommendations: following a diet with a low protein and potassium content, with a calorie content of at least 15,002,000 kcal/day. If it is impossible to eat, balanced parenteral nutrition is indicated, including water, amino acids, fats, carbohydrates, minerals and vitamins. The daily fluid intake should exceed all its losses through urine, vomiting, diarrhea by 400 ml. In postrenal acute renal failure, the main task is to eliminate obstruction of the urinary tract and restore urine passage by endoscopic or surgical methods(catheterization of the ureters, nephrostomy, removal of the ligature from the ureter, ureterocystoanastomosis, etc.).

Drug treatment
Infusion therapy:
- restoration of the effective volume of extracellular fluid with correction of dehydration and hypovolemia, elimination of sodium deficiency;
- combating cardiovascular failure with an increase in cardiac output using anti-shock methods;
- increase in renal blood flow with elimination of renal vasoconstriction, normalization of the function of the renin-aldosterone-angiotensin system.

In case of shock, which in 90% of cases is the cause of tubular necrosis, it is necessary to restore hemodynamics as quickly as possible by using large doses of steroids, large molecular dextrans, plasma, albumin solutions, and starch. Improving renal perfusion in heart failure can be achieved with cardiotropic drugs. For hyponatremia and dehydration, saline solutions are administered. All infusion and transfusion therapy is carried out under careful monitoring of diuresis and central venous pressure.

In the first hours of the development of acute renal failure of any etiology, after stabilization of blood pressure and elimination of hypovolemia, the administration of osmotic diuretics (300 ml of 20% mannitol, 500 ml of 20% glucose solution with insulin) is indicated. Furosemide (200 mg) is administered together with mannitol. The combination of furosemide (30-50 mg/kg/hour) with dopamine (3-6 mcg/kg) for 6-24 hours is especially effective. In acute tubular necrosis and preeclampsia, the administration of osmotic diuretics is contraindicated. With the development of acute renal failure against the background of sepsis or acute pyelonephritis, antibacterial therapy with broad-spectrum antibiotics is carried out against the background of extracorporeal detoxification.

Indications for hemodialysis are: ongoing anuria, progressive deterioration of the condition, increasing azotemia, hyperkalemia (more than 66.5 mmol/l), acidosis and overhydration. With the same level of azotemia, tactics may be different depending on different forms acute renal failure.

Timing and methods of delivery
Emergency delivery according to vital indications on the part of the mother.

Evaluation of treatment effectiveness
Despite the improvement of treatment methods, mortality in acute renal failure remains high and reaches 20% in obstetric and gynecological pathologies, 50% in drug-induced injuries, 70% after injuries and surgical interventions and 80-100% - with multiple organ failure. Among the outcomes, the most common is complete (in 35-40% of cases) or partial recovery (in 10-15%). Death is almost as common - 40-45%. Transition to chronic renal failure is rare (in 1-3% of cases). Acute renal failure is often complicated by infectious and inflammatory diseases of the urinary tract, which can subsequently also lead to chronic renal failure.

Prevention
Timely identification of initial signs of renal dysfunction and hospitalization in a specialized hospital. Treatment of pregnancy complications.

Forecast
The prognosis for the mother and fetus in the absence of timely treatment is undoubtedly unfavorable. Women who have suffered acute renal failure need careful outpatient monitoring and pre-conception preparation when planning pregnancy.

The possibility of pregnancy depends on the degree of restoration of kidney function. Pregnancy can be allowed for patients with completely restored renal function or with minor defects (detected by isotope renography or changes in enzymograms), as well as women who suffered acute renal failure more than 2 years ago. Prolongation of pregnancy is permitted in the absence of renal dysfunction in the first trimester of pregnancy. For patients who have suffered severe forms of acute renal failure and whose kidney function has not recovered after acute renal failure, pregnancy is contraindicated.

CHRONIC RENAL FAILURE
Chronic renal failure is a symptom complex that develops as a result of the gradual death of nephrons as a result of any progressive kidney disease and is characterized by a persistent and irreversible decrease in the mass of functioning nephrons and is manifested mainly by a decrease in the excretory function of the kidneys.

Epidemiology
The incidence of chronic renal failure in different countries ranges from 100 to 600 cases per 1 million adult population with an annual increase of 10-15%. End-stage chronic renal failure develops after 10 years in 85.2% of cases with chronic glomerulonephritis.

Etiology and pathogenesis
The etiological factors of chronic renal failure are varied. The main reasons include:
- diseases that occur with primary damage to the glomeruli (chronic and subacute glomerulonephritis), tubules and interstitium (chronic pyelonephritis, interstitial nephritis);
- diffuse connective tissue diseases occurring with kidney damage;
- metabolic diseases;
- congenital kidney diseases;
- primary vascular lesions;
- obstructive nephropathies.

Despite the variety of etiological factors, morphological changes in the kidneys in chronic renal failure are of the same type and boil down to the predominance of fibroplastic processes with the replacement of functioning nephrons by connective tissue, hypertrophy of the remaining nephrons. An adaptive mechanism for maintaining the glomerular filtration rate at the required level is to increase the load on the remaining nephrons, which hypertrophy. In the latter, hyperfiltration develops, further aggravating their structural changes. Clinical picture

An asymptomatic course of chronic renal failure is possible, but much more often a full-blown clinical picture of uremia is observed. There are 4 stages of chronic renal failure.
Stage I - preclinical (latent) renal failure, characterized by a decrease in GFR to 50-60 ml/min. There may be no clinical manifestations. Sometimes minimal clinical symptoms are detected in the form of weakness, fatigue, dry mouth, decreased appetite, sleep disturbances, and sometimes thirst. Indicators of nitrogen metabolism remain normal, but functional tests can detect a decrease in the secretory activity of the tubules, changes in phosphorus-calcium metabolism, periodic proteinuria, increased excretion of sugars, and disaminoaciduria. When performing the Zimnitsky test, hypoisosthenuria occurs (relative density of urine is less than 1018).
Stage II - compensated, in which the glomerular filtration rate decreases to 49-30 ml/min. The symptoms described above are more persistent. Azotemia levels are normal or at the upper limit of normal. The daily amount of urine increases to 2-2.5 liters as a result of impaired tubular reabsorption, urine osmolarity is reduced, moderate electrolyte disturbances are possible due to increased sodium excretion, changes in phosphorus-calcium metabolism with the development of signs of osteodystrophy. There is moderate normochromic anemia, thrombocytopenia, leukocytosis with a shift to the left, and an increase in the erythrocyte sedimentation rate.
Stage III - intermittent, observed when the glomerular filtration rate decreases to 29-15 ml/min. In this case, persistent azotemia occurs (increased levels of urea to 8-20 mmol/l and creatinine to 0.2-0.5 µmol/l), severe disturbances in electrolyte and acid-base status. This stage is characterized by a more pronounced clinical picture with the complaints described above. There are periods of deterioration in the condition associated with exacerbation of the underlying disease, previous intercurrent diseases, surgical interventions, etc., and improvements after adequate therapy.
Stage IV is terminal, due to further progression of the death of the kidney parenchyma, the glomerular filtration rate decreases to 14-5 ml/min and lower, and is characterized by the irreversibility of changes in the kidneys. The clinical picture corresponds to uremic intoxication, which occurred regardless of the etiological factor.

Diagnostics
Anamnesis
When analyzing anamnestic data, attention is paid to the duration and nature of the course of kidney disease, the presence or absence of arterial hypertension, and surgical interventions.

Instrumental studies
Diagnosis of chronic renal failure is carried out simultaneously with the detection of kidney disease. They conduct clinical and biochemical tests of blood, urine, ultrasound examinations, excretory urography, and use methods that help determine effective renal blood flow, assess glomerular filtration and the state of tubular secretion.

Glomerular filtration decreases parallel to the progression of nephrosclerosis and makes it possible to determine the severity of chronic renal failure and indications for the use and dosage of drugs. Reliable determination of the stage of chronic renal failure is possible only if the active inflammatory process in the kidneys is eliminated and urine passage is restored.

Recommended scope of study:
- ultrasound examination of the kidneys;
- Dopplerography of kidney vessels;
- Magnetic resonance imaging;
- MR survey urography;
- retrograde ureteropyelography;
- kidney biopsy outside pregnancy;
- renal angiography, or nephrography;
- scintigraphy.

Laboratory methods used:
- general blood analysis;
- blood chemistry;
- hemostasiogram
- general urine analysis;
- Rehberg test;
- Zimnitsky test;
- microbiological examination of urine;

Differential diagnosis
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), while in 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; lack of increase in daily diuresis - in favor of chronic renal failure. In some cases, chronic glomerulonephritis manifests itself only as increased blood pressure with a consistently normal urine test. During pregnancy, chronic glomerulonephritis with chronic renal failure may be the initial manifestation of systemic lupus erythematosus.

With all of the above variants of hidden renal pathology in pregnant women, the diagnostic value of analyzing their coagulogram, lipidemia and creatinemia indicators 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.

Screening options for disease detection
Screening patients with end-stage chronic renal disease is difficult, except in obvious cases of familial disease (cystic kidney disease) or known systemic disease (diabetes) that leads to kidney failure. Mandatory appointment general analysis urine at the first visit. Detection of proteinuria or microscopic hematuria suggests possible kidney disease.

Treatment
Goal of treatment
Relief and prevention of severe organ complications.

Indications for hospitalization
If chronic renal failure is suspected, observation and treatment of a pregnant woman is carried out only in a hospital setting.

Non-drug treatment
Chronic (programmed) hemodialysis remains the main treatment method for patients with end-stage renal failure, along with kidney transplantation.

Drug treatment
The drugs of choice for the treatment of arterial hypertension are inhibitors and true angiotensin receptor blockers (AT-II) - ARBs. It has been proven that long-term use of these drugs inhibits the progression of chronic renal failure. Calcium channel blockers are also used, which are advisable to combine with inhibitors or ARBs, as well as selective β-blockers, central and peripheral vasodilators, and potassium-sparing saluretics. Iron supplements are used to correct anemia. Preference is given to preparations of sulfate or fumarate iron, which are well absorbed in the intestine. Taking iron supplements is combined with the use of vitamin supplements (mandatory for hemodialysis patients). To treat anemic syndrome, human recombinant erythropoietin is also used in combination with iron supplements and folic acid.

Choosing the timing and method of delivery
At the compensated stage of chronic renal failure, complications of pregnancy and childbirth are frequent and severe for women and the fetus, therefore pregnancy at this stage of chronic renal failure is contraindicated. Pregnant women with the initial stages of chronic renal failure should be protected from pregnancy by using intrauterine contraceptives, the use of which does not cause exacerbation of the disease, infectious processes in the genitals and hemorrhagic complications. If the patient refuses to terminate the pregnancy, the date and method of delivery are determined depending on the stage of the disease by an obstetrician-gynecologist and nephrologist.

Evaluation of treatment effectiveness
Assessed by the absence of obstetric and somatic complications.

Prevention
Early detection and treatment of diseases contributing to the development of chronic renal failure.

Forecast
In women with chronic renal failure, pregnancy and childbirth are at high risk for the development of complications from the mother, fetus and newborn. Complications of pregnancy are detected in 47% of cases, a successful obstetric outcome is observed in 90%, however, with the addition of preeclampsia before 28 weeks. a successful obstetric outcome is observed only in 59% of cases. After delivery, deterioration in renal function was detected in every 4th woman, and if preeclampsia occurred before 28 weeks, then deterioration in renal function after childbirth occurs in 71% of cases. Considering the deterioration in renal function in the postpartum period, a questionable prognosis for life, pregnancy is contraindicated in such patients.