Preconception and pregnancy management of women with diabetic nephropathy on angiotensin converting enzyme inhibitors.

Angiotensin converting enzyme (ACE) inhibitors are the mainstay of treatment for diabetic nephropathy to slow progression of disease. Diabetic women of childbearing age with nephropathy should be treated with ACE inhibitors as per guidelines in the pre-pregnancy period. ACE inhibitor use and exposure in the first trimester is controversial and requires counselling pre-pregnancy regarding the risks and benefits of use up to the first trimester, as well as the need to stop ACE inhibitors prior to the second trimester. Current evidence does not suggest that ACE inhibitors in the first trimester are associated with a greater risk of fetal malformations when compared to other antihypertensives. This topic is reviewed in depth, along with blood pressure targets in pregnant women with diabetic proteinuric disease, evidence for prevention of pre-eclampsia, self-monitoring of blood pressures at home in the latter half of pregnancy and the signs and symptoms of pre-eclampsia, proteinuria evolution in pregnancy, renal function prognosis, and restarting ACE inhibitors when breast feeding in the post-partum period.

Extravascular lung water and peripheral volume status in hemodialysis patients with and without a history of heart failure.

Determining volume status in hemodialysis patients with a history of congestive heart failure (CHF) is difficult. Extravascular lung water (EVLW) may be derived from blood ultrasound velocity changes following injections of 0.9% and 5% saline. Bioimpedance spectroscopy can measure total body water (TBW) and its intracellular fluid (ICF) and extracellular fluid (ECF) compartments. We studied 29 clinically euvolemic hemodialysis patients, 12 of whom had a history of CHF. The ECF and ICF were measured before dialysis, and EVLW was measured during dialysis. Values of EVLW were similar between patients without CHF and those with CHF (3.55 ml/kg +/- 0.94 SD versus 3.88 ml/kg +/- 0.82 SD, respectively; p = NS). The ECF/ICF ratio was higher among patients with a history of CHF (1.27 +/- 0.29) than among those without such a history (1.04 +/- 0.04; p < 0.05), indicating that ECF volume overload was present in both groups, but was higher in those with a CHF history. There was a positive correlation between EVLW and ECF/ICF ratios (r = 0.54, p < 0.01). Measurements of EVLW were higher in two pulmonary edema patients ((7.95 ml/kg and 5.95 ml/kg; p < 0.05). The results of this study suggest that 1) hemodialysis patients with a history of CHF have more ECF volume overloaded than those without such a history; 2) the degree of ECF expansion is associated with increasing EVLW volume, even in patients without pulmonary edema; and 3) ECF volume expansion eventually exceeds limits and pulmonary edema occurs. These developing technologies of volume measurement may be of value in this challenging clinical area.

Determining lung water volume in stable hemodialysis patients.

Lung water (LW) reflects the water content of the lung interstitium. Because hemodialysis patients have expanded total body water (TBW) they may also have increased LW. Hypertonic saline promotes a flux of water from lung to blood, which is measured by ultrasound flow probes on hemodialysis tubing. The volume of flux is an indirect measure of LW. Our purpose was to determine the feasibility and reproducibility of LW derived with ultrasound velocity dilution, to determine the effect of ultrafiltration on LW in stable hemodialysis patients, and to compare changes in LW with fluid compartment shifts using bioimpedance. Lung water, cardiac output, total body water, and extracellular and intracellular fluid volumes were measured in 24 stable hemodialysis patients at the beginning of hemodialysis and after ultrafiltration. The LW values at the beginning of hemodialysis (298.8 +/- 90.2 ml or 3.67 +/- 1.47 ml/kg) fell during hemodialysis (250.8 +/- 55.8 ml or 3.12 +/- 0.96 ml/kg; p < 0.05), as did TBW and extracellular fluid volumes (p < 0.001). Cardiac output, cardiac index, and central blood volume also decreased significantly with ultrafiltration (p < 0.005, p < 0.005, and p < 0.01, respectively). Results showed that stable hemodialysis patients have higher specific LW values (3.67 ml/kg) than the normal population (2 ml/kg) and ultrafiltration produces a significant decline in LW values.

Obstetric medical care in Canada.

Obstetric medicine is a growing area of interest within internal medicine in Canada. Canadians continue to travel broadly to obtain relevant training, particularly in the United Kingdom. However, there is now a sufficient body of expertise in Canada that a cadre of 'home-grown' obstetric internists is emerging and staying within Canada to improve maternity care. As this critical mass of practitioners grows, it is apparent that models of obstetric medicine delivery have developed according to local needs and patterns of practice. This article aims to describe the state of obstetric medicine in Canada, including general internal medicine services as the rock on which Canadian obstetric medicine has been built, the Canadian training curriculum and opportunities, organisation of obstetric medicine service delivery and the future.

Maternal, pregnancy and fetal outcomes in de novo anti-glomerular basement membrane antibody disease in pregnancy: a systematic review.

BACKGROUND: Outside of pregnancy, anti-glomerular basement membrane (GBM) antibody disease is associated with significant morbidity and mortality. However, there is limited knowledge regarding de novo anti-GBM disease in pregnancy. METHODS: A systematic review was performed to identify maternal, pregnancy and fetal outcomes in de novo anti-GBM disease in pregnancy. Studies were selected from PubMed, EMBASE, Cochrane Library databases and conference proceedings, without language restriction. RESULTS: Data from eight patients were derived from seven case reports and one unpublished case. Most (6/8) patients presented after the first trimester. During pregnancy, acute kidney injury (5/8), anemia (5/8), hematuria (8/8) and proteinuria (8/8) were common. When hemodialysis was required antepartum (5/8), renal function recovery to independence of renal replacement was unlikely (2/5). While pulmonary involvement was common (5/8), no permanent damage was reported (0/8). The majority of cases ended in live births (6/8) although prematurity (6/6), intrauterine growth restriction (2/6), small for gestational age (4/6) and complications of prematurity (1/6) were common. When anti-GBM levels were tested in the living newborn, they were detectable (2/5), but no newborn renal or lung disease was reported (0/6). Complications in pregnancy included gestational diabetes (3/8), hyperemesis gravidarum (2/8) and preeclampsia (2/8). CONCLUSIONS: Live births can be achieved in de novo anti-GBM disease in pregnancy, but are commonly associated with adverse maternal, pregnancy and fetal outcomes. Only with awareness of common presentations, and management strategies can outcomes be optimized.

Pregnancy outcomes in women with chronic kidney disease: a systematic review.

BACKGROUND AND OBJECTIVES: Pregnant women with chronic kidney disease (CKD) are at risk of adverse maternal and fetal outcomes. We conducted a systematic review of observational studies that described this risk. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We searched several databases from their date of inception through June 2010 for eligible articles published in any language. We included any study that reported maternal or fetal outcomes in at least five pregnant women in each group with or without CKD. We excluded pregnant women with a history of transplantation or maintenance dialysis. RESULTS: We identified 13 studies. Adverse maternal events including gestational hypertension, pre-eclampsia, eclampsia, and maternal mortality were reported in 12 studies. There were 312 adverse maternal events among 2682 pregnancies in women with CKD (weighted average of 11.5%) compared with 500 events in 26,149 pregnancies in normal healthy women (weighted average of 2%). One or more adverse fetal outcomes such as premature births, intrauterine growth restriction, small for gestational age, neonatal mortality, stillbirths, and low birth weight were reported in nine of the included studies. Overall, the risk of developing an adverse fetal outcome was at least two times higher among women with CKD compared with those without. CONCLUSIONS: This review summarizes current available evidence to guide physicians in their decision-making, advice, and care for pregnant women with CKD. Additional studies are needed to better characterize the risks.