Injuria(Renal(Aguda(Obstétrica:(

Claves(en(el(Diagnós:co(Diferencial(

Dr.(Eric(Roessler(B(

Unidad(de(Procedimientos(Nefrológicos(

Departamento(de(Nefrología(UC(

Gamill(H,(Arundhathi(J.(Crit(Care(Med(33:(S372P384.(2005(

Glomerular(Filtra:on(Rate(and(Effec:ve(Renal(Plasma(

Flow(During(Pregnancy(

Gamill(H,(Arundhathi(J.(Crit(Care(Med(33:(S372P384.(2005(

Normal(Laboratory(Variables(in(pregnancy!

n" %"AKI( 54! $!

AKIN(1( 52! 96!

AKIN(2( 0! $!

AKIN(3( 2! 4!

""n":"1781"("AKI":"3%)""

n":"63882"("AKI":"0,08%)"!

0!

0,005!

0,01!

0,015!

0,02!

0,025!

0,03!

0,035!

1960!$!70s! 1980!$!90s!

Incidence((%(Pregnancies)(

Stratta P, Besso L, Canavese C, Benedetto C, Hollo S: Is Pregnancy Related Acute Renal Failure a Dissapearing Entity? Ren$Fail$18:!575$584,!1996.!

0!

20!

40!

60!

80!

100!

120!

1960s! 1980s!

PRPAKI(

Overal(AKI(

Turney J, Ellis C, Parsons F: Obstetric acute renal failure 1956 – 1987. Br$J$Obstet$Gynaecol$1989;!96:679$687.!

1:56(

Obstetric(RCN:(((((((((((56%(Non(Obstetric(RCN:((46%((

Necrosis(Cor:cal(en(AKI(Obstétrica(

•  App(3%(de(casos(de(AKI(•  50%(Obstétricas(•  NC(Bilateral(reportada(hasta(en(30%(de(AKI(Obstétrica(

•  Alta(incidencia(en(Abrupto(Placentario(y(Aborto(sép:co(

•  Baja(Incidencia(en(PE(severa(•  Mayor(daño(endotelial(en(presencia(de(LPS,(

isquemia(y(CID(!(Efecto(Swartzman(

Caso(Clínico(1(

•  Mujer!29!años!•  Embarazo!38!semanas!

•  Fracaso!Inducción!•  Cesárea!de!urgencia!•  Inercia!Uterina!y!Shock!

Hemorrágico!(!Hto!Ingreso!6%)!

•  SDRA!•  HVHF!

Amnio:c(Fluid(Embolism(

Caso(Clínico(2(

•  30!Años!M1!–!embarazo!32+1!•  PA!140/100!+!cefalea,!albuminuria!++!y!alza!de!peso!5!kgrs!en!1!mes!

!•  Ingreso:(PA:!150/95!Scr!1.6!–!Sin!oliguria!IPC!2.1!–!Alb!Normal!ROT!Normales!Urico!6.2!mg/dl!.!P.!Hepá`cas!normales!Ex!cardiopulmonar!Normal!!

0!

0,5!

1!

1,5!

2!

2,5!

3!

Dia!1! Dia!2! Dia!3! Dia!5! Dia!6! Dia!8! dia!11!

SCr(

SCr!

IgA(

Sin(Endoteliosis(en(M.O(

Scr:((((((((((((1.5(mg/dl(

Uprot:(((((((1.7(grs/24(hrs(

Biopsia(Renal(

MAT(Asociada(al(Embarazo((EPMAT)(

•  MAT!asociada!a!desregulación!del!complemento!•  MAT!asociada!a!Déficit!de!ADAMTS!13!•  MAT!asociada!a!otros!mecanismos!(Verotoxina,!déficit!de!

VEGF).!

•  E$MAT!es!una!forma!secundaria!de!MAT!•  8!a!18%!de!los!casos!de!MAT!•  80!%!3er!trimestre!•  30%!AKI!•  Hasta!10%!Mortalidad!•  MAT$DC!:!80%!postparto!(Eculizumab)!

Sindrome((HELLP!

•  Clinicamente(hemólisis(intravascular(+(alteración(P(

Hepá:cas(

•  AKI(en(3(a(15%(casos(de(HELLP(•  HELL(causa(hasta(60%(Casos(de(AKI(obstétrica(severa(•  90(–(100%(Recuperación(renal(completa(

•  Menos(de(10%(Progresión(a(CKD(

•  Elementos(de(MAT(en(la(biopsia(renal(solo(en(15%(

•  Endoteliosis(glomerular(y(NTA(

•  ¿(HELLP(es(una(forma(de(MAT(renal?(

Terapia(de(Reemplazo(Renal(en(AKI(

Obstétrica(

•  Timing(?(

•  Potenciales(efectos(nega:vos(en(Flujo(placentario(

•  Terapias(con:nuas(Vs(Intermitentes(?(

•  Dosis(?(•  Mayoria(de(la(evidencia(disponible(

proviene(de(HD(crónica(en(embarazo(

(“Ambiente(uremico(intrauterino”).(

•  Death:(30.9%(

•  Complete(Recovery:(52.7%(

GRACIAS"