Table Of ContentPREGNANCY AND
RENAL DISORDERS
Other titles in the New Clinical Applications Series:
Dermatology (Series Editor Dr J. L. Verbov)
Dermatological Surgery
Superficial Fungal Infections
Talking Points in Dermatology-I
Treatment in Dermatology
Current Concepts in Contact Dermatitis
Talking Points in Dermatology-II
Tumours, Lymphomas and Selected Paraproteinaemias
Relationships in Dermatology
Cardiology (Series Editor Dr D. Longmore)
Cardiology Screening
Rheumatology (Series Editors Dr J. J. Calabro and Dr W. Carson
Dick)
Ankylosing Spondylitis
Infections and Arthritis
Nephrology (Series Editor Professor G. R. D. Catto)
Continuous Ambulatory Peritoneal Dialysis
Management of Renal Hypertension
Chronic Renal Failure
Calculus Disease
Pregnancy and Renal Disorders
Multisystem Diseases
Glomerulonephritis I
Glomerulonephritis II
NEW
CLINICAL
APPLICATIONS
NEPHROLOGY
PREGNANCY AND
RENAL
DISORDERS
Editor
G. R. D. CATTO
DSc, MD, FRCP, (Land., Edin. and Glasg.)
Professor in Medicine and Therapeutics
University of Aberdeen
UK
KLUWER ACADEMIC PUBLISHERS
DORDRECHT / BOSTON / LONDON
Distributors
for the United States and Canada: Kluwer Academic Publishers, PO Box 358,
Accord Station, Hingham, MA 02018-0358, USA
for all other countries: Kluwer Academic Publishers Group, Distribution Center, PO Box 322,
3300 AH Dordrecht, The Netherlands
British Library Cataloguing in Publication Data
Pregnancy and renal disorders.
1. Pregnant women. Kidneys. Diseases
I. Catto, Graeme R.D. (Graeme Robertson
Dawson), 1945- II. Series
618.3'26
Library of Congress Cataloging-in-Publication Data
Pregnancy and renal disorders/editor, G.R.D. Catto.
p. cm.---{New clinical applications. Nephrology)
Includes bibliographies and index.
ISBN-13: 978-94-0lO-7680-7 e-ISBN-13: 978-94-009-2615-8
DOl: 10.1007/978-94-009-2615-8
1. Kidney diseases in pregnancy. I. Catto, Graeme R. D.
II. Series.
[DNLM: 1. Kidney Diseases-in pregnancy. 2. Pregnancy
Complications. WJ 300 P923]
RG580.K5P74 1988
618.3'26---dc19
DNLM/DLC
for Library of Congress 88-8369
CIP
Copyright
© 1988 by Kluwer Academic Publishers
Softcover reprint of the hardcover 1st edition 1988
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without prior permission
from the publishers, Kluwer Academic Publishers BY, PO Box 17,3300 AA
Dordrecht, The Netherlands.
Published in the United Kingdom by Kluwer Academic Publishers,
PO Box 55, Lancaster, UK.
Kluwer Academic Publishers BY incorporates the publishing programmes of
D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press.
Butler & Tanner Ltd, Frome and London
CONTENTS
List of Authors VI
Series Editor's Note Vll
About the Editor Vlll
1. Urinary Tract Infection
K. Verrier Jones
2. Chronic Renal Failure 41
C. P. Swainson
3. Pregnancy in Dialysis and Transplant Patients 51
H.A. Lee
4. Pregnancy and Diabetic Nephropathy 65
D. W. M. Pearson and H. W. Sutherland
5. Collagen Vascular Disorders 91
A.M. MacLeod
Index 111
v
LIST OF AUTHORS
H.A.Lee H. W. Sutherland
Department of Renal Medicine Department of Obstetrics and
University of Southampton Gynaecology
St Mary's Hospital Aberdeen Maternity Hospital
Portsmouth Cornhill Road
Hampshire P03 6AD Aberdeen AB9 2ZA
UK UK
c.
A.M. MacLeod P. Swainson
Department of Medicine and Medical Renal Unit
Therapeutics Department of Medicine
University of Aberdeen Royal Infirmary
Pol warth Building Edinburgh EH3 9YW
F oresterhill UK
Aberdeen AB9 2ZD
UK K. Verrier Jones
Department of Child Health
D. W.M. Pearson University of Wales College of
Diabetic Clinic Medicine
W oolmanhill Royal Infirmary
Aberdeen Royal Infirmary Cardiff CF2 1S Z
Aberdeen AB9 1G S UK
UK
VI
SERIES EDITOR'S FOREWORD
Almost every practising doctor will admit to difficulty in knowing how
best to investigate, treat and advise the pregnant patient with renal
problems. These doubts and difficulties may be exacerbated if the
patient seeks pre-pregnancy advice - would a possible pregnancy cause
a deterioration in renal function, what are the risks of the pregnancy
for mother and baby? As the general public become more informed
on medical matters these questions are being asked more frequently
and doctors must be prepared to offer advice which is based on detailed
factual knowledge.
This book examines some of these increasingly common clinical
problems. Each chapter has been written by a recognized expert in the
field and provides the type of specific information now expected by
discerning patients. The advances in treatment of the last decade
clearly indicate that a knowledge of pregnancy and renal disorders is
essential for doctors in many branches of medical practice.
G. R.D. CATTO
VII
ABOUT THE EDITOR
Dr Graeme R. D. Catto is Professor in Medicine and Therapeutics at
the University of Aberdeen and Honorary Consultant Phy
sician/Nephrologist to the Grampian Health Board. His current inter
est in transplant immunology was stimulated as a Harkness Fellow at
Harvard Medical School and the Peter Bent Brighton Hospital,
Boston, USA. He is a member of many medical societies including
the Association of Physicians of Great Britain and Ireland, the Renal
Association and the Transplantation Society. He has published widely
on transplant and reproductive immunology, calcium metabolism and
general nephrology.
viii
1
URINARY TRACT INFECTION
K. VERRIER JONES
INTRODUCTION
It is well known that symptomatic urinary tract infection, particularly
acute pyelonephritis, occurs more often during pregnancy than in non
pregnant women of comparable age or younger or older women.
However, there is no evidence that asymptomatic bacteriuria (ASB)
is more common during pregnancy than in non-pregnant womenl.
Because of the severe acute illness often produced during pregnancy
as a result of urinary tract infection, and because this may have an
adverse effect on the course of the pregnancy and on the fetus, there
has been considerable interest in this condition. In the pre-antibiotic era
it was possible to observe the natural history of acute pyelonephritis2,3.
Some unfortunate women continued to have fever and loin pain for
many weeks. In some, symptoms improved after delivery, whilst in
others, symptoms continued into the puerperium. In 1939, Weiss
and Parker vividly described the course of a woman with chronic
pyelonephritis, with pregnancy-associated hypertension and toxaemia,
who subsequently developed dysuria, backache, retinal haemorrhages,
acute pyelonephritis, septicaemia and anaemia in relation to one
successful pregnancy and one which ended in a spontaneous abortion
at 19 weeks4• Whilst this type of illness with severe underlying renal
disease is seen only occasionally, and both hypertension and infection
can be treated successfully, acute pyelonephritis remains a serious,
occasionally life threatening, but treatable condition in pregnancy.
The incidence and morbidity of acute pyelonephritis and its com-
PREGNANCY AND RENAL DISORDERS
plications can be significantly reduced by screening for ASB5 and by
prompt diagnosis and early treatment of any cases of symptomatic
infections when they occur.
There are many different clinical presentations of urinary tract
infection and those which are relevant to pregnancy will be discussed
in further detail later in this chapter. Urinary infection in women is
frequently a persisting or recurring condition6. The relationship
between covert infection, symptomatic infection, treatment and com
plications is summarised in Figure 1.1. There is little evidence that
acute infection at the time of pregnancy causes permanent renal
damage but transient abnormalities of renal function are present
with upper urinary tract infection7,8. Acute renal failure is a rare
complication of acute pyelonephritis in pregnancy but women with
chronic pyelonephritis and impaired renal function may experience a
more rapid decline in renal function following pregnancy9, particularly
if blood pressure is poorly controlled. Septicaemia and persisting or
relapsing infection are usually confined to those women who have
FIGURE 1.1 Relationship between asymptomatic and symptomatic
infection, treatment. reinfection and renal damage
2
