Renal Disease in Pregnancy

I.   Program Content

1. Trainees must acquire knowledge and understanding of the following areas during the course of their training.

1. Changes in the anatomy and funciton of the urinary tract during pregnancy, focusing on the relevance of these changes to clinical circumstances, stressing alterations in the calyces and ureters, renal hemodynamics, and tubular funciton (principally potassium and glucose).

2. Changes in acid-base metabolism in pregnancy, focusing on normal pH, HCO3, and PCO2.

3. An integrated view of volume homeostasis during pregnancy.  This includes knowledge of the normal gestational changes in weight, intravascular and extracellular volume status, renal salt handling, and the production of volume regulating hormones.

4. Altered osmoregulation in pregnancy, focusing on changes in plasma sodium and osmolality levels, as well as on certain disorders of water metabolism peculiar to gestation.

5. The course and control of blood pressure in normal pregnancy.

6. Tests of kidney function, including indications for renal biopsy during pregnancy.

7. Be familiar with the clinical spectrum and management of renal disorders in gestation.  This includes: pathogenesis and treatment of urinary tract infections; acute renal fialure (especially those primarily associated with gestation, i.e., septic abortion, abruption, preeclampsia, acute fatty liver, and idiopathic postpartum renal failure); and chronic glomerular and interstitial renal disease antedating pregnancy.

8. Recognize the presentation of stone disease during gestation, and be familiar with the effect of pregnancy on patients with nephrolithiasis. 

9. Be familiar with the administration of both acute and chronic renal replacemtn therapy in pregnant women.

10. Know the effects of pregnancy on the natural history of renal allografts, and conditions required for undertakign pregnancy in transplant recipients.

11. Recognize and treat the hpyertesnive disorders of pregnancy, particularly preeclampsia and its variants such as the “HELLP” syndrome.  This includes the use in gravidas of antihypertensive drugs, and the prevention and treatment of eclampsia, including the administration of magnesium sulfate.

12. Be capable of performing preconception counseling pertinent for the maternal and fetal prognosis for women with chronic hypertension and/or underlying kidney disorders.

II.   Patient Care Experience

1. Trainees must diagnose and manage women whose pregnancy is complicated by acute or chronic renal dysfunction as well as gestations complicated by hypertesnion.  They should have exposure to the presentation and management of gravidas experiencing acute hypertensive crises, espcially those crises complicated by systemic manifestations such as liver dysfunction, thrombocytopenia, and microangiopathic hemolytic anemia.