Pathophysiology of Hypertensive Disorders KIDNEY

NORMAL PREGNANCY
Renal Blood Flow is increased.
Glumerular Filtration Rate is increased.
PREECLAMPSIA
Renal perfusion is decreased.
Glumerular filtration is decreased
- Results from reduced plasma volume
Urine Sodium concentration is increased.
Presence of indicators of prerenal mechanism:
a. Urinary Osmolality
b. Urine:Plasma Creatinine Ratio
c. Fractional Excretion of Sodium
Plasma Uric Acid Concentration is increased.
- Elevation exceeds the reduction in GFR.
- Due to enhanced tubular reabsorption.
Diminished urinary excretion of Calcium.
- Due to increased tubular reabsorption.
Increased placental Urate production.
- Compensatory to increased oxidative stress.
Most of the decrement is from increased renal afferent arteriolar resistance
(5x).
Morphological Changes:
Glumerular Endotheliosis
- Blocks the filtration barrier
- Diminished filtration causes serum creatinine levels to rise to values
seen in nonpregnant individuals, that is, 1 mg/mL or even higher.
- Abnormal value begins to normalize 10 days or later after delivery.
PROTEINURIA
Will establish the diagnosis of preeclampsia syndrome
May develop late (have delivered or have eclamptic convulsion)
Dipstick Qualitative Measurement:
o Depends on urinary concentration
o Notorious for false-positive & -negative results
24-hour Quantitative Specimen
o consensus threshold value: >300 mg/24h or 165 mg/12 h sample
o Urinary Protein:Creatinine Ratio
VALUE
IMPLICATION
<130 to 150 mg/g or 0.13 to 0.15
Low likelihood of proteinuria exceeding
300 mg/day
Midrange Ratios: 300 mg/g or 0.3
Poor sensitivity & specificity

Recommendation: With midrange ratios, 24-hour excretion should be

quantified.
Measurement of Proteinuria:
Albumin Excretion
- More accurate
- Albumin filtration exceeds that of larger globulins
- In preeclampsia, most of proteins in the urine is albumin
o

Increasing proteinuria is more common in multifetal pregnancy complicated

by preeclampsia.

ANATOMICAL CHANGES
A. Glumeruli
Enlarged by approximately 20%.
bloodless
Capillary loops are dilated and contracted.
B. Endothelial Cells
Swollen, blocks or partially blocks capillary lumen
Glumerular Capillary Endotheliosis
Homogenous subendothelial deposits of proteins and fibrin-like
materials are seen
Results from antiangiogenic factor withdrawal caused by free
angiogenic proteins complexing with the circulating antiangiogenic
receptor.
Angiogenic Factors
- Crucial for podocyte health
- Inactivation leads to podocyte dysfunction and endothelial swelling
- Markers: excretion of
a. Nephrin
b. Podocalyxin
c. Big-h3 (transforming growth factor, Beta-induced)
Eclampsia
o Characterized by excretion of urinary podocytes(epithelia)
Renal pathology involves both endothelial and epithelial cells.
ACUTE KIDNEY INJURY
Acute Tubular Necrosis
o Rarely caused by preeclampsia alone
o Induced by coexisting hemorrhage with hypovolemia and
hypotension
o Usually caused by severe obstetrical hemorrhage for which
adequate blood replacement is not given

 Rarely, Renal Cortical Necrosis develops.