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Management of Renal D i s e a s e in Preg n a n c y Tiina Podymow, MDa, Phyllis August, Ayub Akbari, MDc,*
b MD, MPH ,
KEYWORDS Pregnancy Renal disease Glomerulonephritis Dialysis Renal function
In patients with renal disease who become pregnant, the possible harmful effects of pregnancy on kidney function and the impact of renal disease on pregnancy outcome should be considered. In this context, the nephrologist's role is to assess the risk for worsening renal function in pregnancy; ideally nephrologic opinion should be sought before conception. Assessment of maternal hypertension is also crucial, because it contributes significantly to the risk for deteriorating renal function and increases the risk for preeclampsia, preterm delivery, intrauterine growth restriction, and perinatal mortality. Management of pregnant women with kidney disease may be complicated, and requires an understanding of the physiologic changes associated with pregnancy and close teamwork between obstetricians and nephrologists. Although some areas in obstetric medicine have been extensively studied in randomized controlled trials (eg, prevention of preeclampsia), renal disease in pregnancy has been so less commonly, and the quality of the evidence guiding clinical practice has not been of the highest level. Most evidence consists of case series with modest numbers of subjects. Based on population studies, the prevalence of chronic kidney disease in women of childbearing age is 0.03% to 0.2% of all pregnancies. RENAL ANATOMY AND PHYSIOLOGY IN PREGNANCY Anatomic and Functional Changes in Urinary Tract
Normally in pregnancy, increased renal blood flow and glomerular hypertrophy result in an increase in kidney length of approximately 1 cm during normal gestation, and overall kidney volume increases by up to 30%.1 The major anatomic alterations of the urinary
Division of Nephrology, McGill University, 687 Pine Avenue West Ross 2.38, Montreal, QC H3A 1A1, Canada b Division of Nephrology and Hypertension, Weill Medical College of Cornell University, 525 East 68th Street, Starr 437, NY 10021, USA c Division of Nephrology, University of Ottawa, Kidney Research Center, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada * Corresponding author. E-mail address: email@example.com Obstet Gynecol Clin N Am 37 (2010) 195–210 doi:10.1016/j.ogc.2010.02.012 obgyn.theclinics.com 0889-8545/10/$ – see front matter ª 2010 Elsevier Inc. All rights reserved.
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tract during pregnancy are seen in the collecting system, where calyces, renal pelvises, and ureters dilate, often giving the erroneous impression of obstructive uropathy.2 The cause of the ureteral dilation has been attributed to hormonal mechanisms, such as increased progesterone, and mechanical obstruction by the enlarging uterus. These morphologic changes result in stasis in the urinary tract and a higher risk among pregnant women with asymptomatic bacteriuria for progression to pyelonephritis, particularly in those who have a history of prior urinary tract infections.3 Rarely, ''overdistension syndrome'' may occur, which is a pregnancy-related syndrome characterized by severe hydronephrosis, abdominal pain, decline in renal function, and even hypertension, which may respond to lateral recumbency or require stent placement. Renal Hemodynamics in Pregnancy
Marked vasodilation is a hallmark of pregnancy and occurs by 6 weeks gestation. Vasodilation is accompanied by a decrease in blood pressure, increase in cardiac output, and increases in renal plasma flow and glomerular filtration, all of which persist until late gestation. Increased progesterone, estrogen, nitric oxide, and relaxin have all been implicated as vasodilatory mediators. Because renal plasma flow increases slightly more than the glomerular filtration rate (GFR), filtration fraction remains constant or slightly lower in pregnancy. Increases in renal hemodynamics reach a maximum during the first trimester, and levels are approximately 50% greater than those of prepregnancy.4 The increase in GFR (hyperfiltration) during normal pregnancy occurs without increase in intraglomerular pressure, and normal pregnancy is not injurious to the maternal kidney. Acid–Base Regulation in Pregnancy
Because of the increased circulating level of progesterone, which directly stimulates the medullary respiratory center, tidal volume and alveolar ventilation are increased during pregnancy, resulting in respiratory alkalosis, with reduced arterial PCO2. To compensate, the kidneys excrete more bicarbonate in pregnancy, which results in a 4- to 5-mEq/L decrease in serum bicarbonate to 20 to 22 mEq/L, changes that are apparent in the first trimester.5 Compared with nonpregnant patients, the normal anion gap in pregnancy is lower at 8.5 2.9, and normal strong ion difference ([Na1] 1 [K1] – [Cl-]) is 38.3 2.9.6 Finally, a PCO2 of 40 mm Hg signifies considerable carbon dioxide retention in pregnancy. Water Metabolism
Pregnancy is associated with a decrease in plasma osmolality of 5 to 10 mOsm/kg lower than that of nongravid women, reaching a nadir at 10 weeks gestation. The decrease in plasma osmolality is associated with appropriate responses to water loading and dehydration, and suggests a resetting of the osmoreceptor system, with thirst occurring at lower serum osmolality. Clinical studies showing decreased osmotic thresholds for thirst and arginine vasopressin (AVP) release in pregnant women support this hypothesis. The lower osmolality and serum sodium represent a new normal set-point. In addition to these changes, pregnant women metabolize AVP more rapidly because of increased production of placental vasopressinases.7 Pregnant women may develop syndromes of transient diabetes insipidus from the increased metabolism of AVP. These syndromes may be treated with pharmaceutical desmopressin, which remains effective because of a different N-terminus that is resistant to the circulating vasopressinases. Serum sodium is also lower in pregnancy, which may be caused partly by relaxin, a peptide hormone in the insulin family that is secreted by the corpus luteum and
Management of Renal Disease in Pregnancy
placenta during human gestation. Relaxin is associated with osmoregulatory changes and increases in GFR and vasodilation in early pregnancy.8 Human chorionic gonadotropin seems to cause release of relaxin, which then stimulates the subfornical organ in the hypothalamus, resulting in thirst and AVP secretion. Chronic administration of relaxin to rats mimics several of the hemodynamic and osmotic changes of pregnancy, whereas antirelaxin antibodies reverse these changes. Volume Regulation in Pregnancy
Total body water increases by 6 to 8 L during pregnancy, 4 to 6 L of which is extracellular. Plasma volume increases 50% during gestation, with the largest rate of increment occurring mid-pregnancy. Although serum sodium measurement decreases, a daily positive balance of 2 to 5 mEq and gradual accumulation of approximately 900 mEq of sodium is present during pregnancy (approximately 20 g of sodium chloride), which is distributed between the products of conception and the maternal extracellular space. Despite the increase in plasma volume during pregnancy, no evidence shows a hypervolemic (ie, overfilled circulation) state during pregnancy. Vasodilation, which is observed as early as the first trimester, may be the stimulus for increased sodium retention and increased plasma volume. The observations that blood pressure is significantly lower and the renin–angiotensin system is stimulated during normal pregnancy are consistent with primary vasodilation preceding and causing the increase in plasma volume. Physiology of Renal Disease in Pregnancy
In patients with abnormal prepregnancy renal function, pregnancy may adversely affect maternal renal function, causing it to deteriorate irreversibly, both during gestation and after delivery. The causes are not altogether clear, although exacerbation of preexisting endothelial dysfunction, alterations in immune function, and increased inflammation associated with pregnancy may contribute. Platelet aggregation, formation of fibrin thrombi, and microvascular coagulation have also been implicated in renal and placental dysfunction. In general, the closer to normal the GFR and blood pressure, the greater the chance of successful pregnancy. Assessment of Renal Function in Pregnancy
During pregnancy, GFR and creatinine clearance increase by 40% to 65% and creatinine production is unchanged; therefore, the increased clearance results in decreased serum levels. One study reported average values of 0.83 mg/dL (73 mmol/L) in nonpregnant women, and 0.74, 0.58, and 0.53 mg/dL (65, 51, and 46 mmol/L, respectively) in first, second, and third trimester of pregnancy, respectively, with values for the upper limit of normal of 0.96, 0.90, and 1.02 mg/dL (85, 80, and 90 mmol/L, respectively).9 In the nonpregnant population, the Cockroft-Gault and MDRD (Modification of Diet in Renal Disease) formulae are most commonly used to assess kidney function. Neither of these have been validated in pregnancy. The Cockroft-Gault formula uses body weight as a surrogate for muscle mass, but because the weight of a gravid women increases without affecting the muscle mass, using pregnancy weight in this formula yields inaccurate results. In one study using prepregnancy weight, the formula better approximated creatinine clearance. The MDRD formula yields results that are corrected for body surface area, but because the body surface area changes in pregnancy, this too yields inaccurate results. In one study, MDRD formula underestimated GFR by more than 40 mL/min.
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Measurement of serum cystatin C had been proposed as a more sensitive marker for GFR because it was believed to be independent of age, weight, height, or muscle mass; however this has not been proven when studied in pregnancy.10 Creatinine clearance measured with 24-hour urine collection remains the best approximate of the gold standard of inulin clearance, and is the most well-validated method for measuring renal function. Because of the increased GFR in pregnancy, the tubular transport maximum is exceeded and reabsorption is decreased, causing increased excretion of glucose, amino acids, calcium, and urinary protein. The upper limit of normal for urinary protein excretion is 300 mg/d in pregnant patients versus 150 mg/d in nonpregnant patients. Abnormal proteinuria has been evaluated with 24-hour urine collection, urine dipstick, and protein/creatinine ratio, but the gold standard remains the 24-hour urine protein measurement. A 24-hour protein level greater than 300 mg is abnormal in pregnancy and correlates with a urine dipstick 11 protein measurement. Although commonly used in an obstetrician's office to detect significant proteinuria, urine dipstick testing is susceptible to error because of variations in urine concentration, and may miss up to 1 of 11 hypertensive pregnant women with true proteinuria.11 Therefore, if the level of suspicion is high, 24-hour urine testing should be performed. Total protein/creatinine ratio has been shown to accurately estimate 24-hour urine protein in nonpregnant patients and, according to a systematic review of 13 studies of pregnant patients, seems to be of value in ruling out proteinuria if less than 0.25 g per 24 hours. Misclassifications tend to occur when the proteinuria is borderline (250–400 mg/d), and therefore the 24-hour collection should be performed to diagnose preeclampsia if the results are equivocal. The protein/creatinine measurement also underestimates severe proteinuria in pregnancy, and therefore cannot be recommended as an alternative to 24-hour measurement.12 KIDNEY DISEASE IN PREGNANCY
Kidney disease during pregnancy may be caused by (1) preexisting renal disease that was diagnosed before conception, (2) chronic renal disease that was unappreciated before pregnancy and diagnosed for the first time during pregnancy, or (3) renal disease that develops for the first time during pregnancy. Some overlap exists with respect to the different diseases that are typical of the three categories. For example, lupus nephritis may be a chronic condition, or it may develop for the first time during pregnancy. Chronic Renal Disease: General Principles
Fertility and ability to sustain an uncomplicated pregnancy are related to the degree of renal functional impairment rather than to the specific underlying disorder. The greater the functional impairment and higher the blood pressure, the less likely the pregnancy will be successful (Table 1). Patients with preserved renal function and normal or wellcontrolled blood pressure have favorable maternal and fetal outcomes. Those with mildly elevated creatinine, such as 1.2 to 1.4 mg/dL (106–124 mmol/L) seem to have some risk (16% in one study) for renal function decline. Those with moderate renal insufficiency (serum creatinine 1.4–2.5 mg/dL, or 124–220 mmol/L) are at increased risk for preeclampsia (20%–30%) and preterm delivery. Of these women, approximately 50% have a pregnancy-related decline in creatinine clearance (by 25%), and the renal function decline seems to persist or progress after delivery. Women with severe renal dysfunction, defined by a creatinine level greater than 2.5 mg/dL [220 mmol/L], should be discouraged from conceiving because 70% will experience
Management of Renal Disease in Pregnancy
Table 1 Effect of pregnancy on renal disease Author
No. Pregnant Patients
Renal Diagnosis
Clinical Status at Baseline
Katz et al52
Serum Cr % 1.4 mg/dL
16% transient worsening of renal function
Abe et al53
GFR >70 mL/min
No change
Jungers et al54
Normal GFR
No change
Abe et al55
IgA nephropathy
GFR mean 70 mL/min
Glomerular disease
GFR >70 mL/min GFR <50 mL/min
19% had renal function decline, 4% progressed to ESRD or dialysis 1–5 years after delivery Good if GFR >70 and blood pressure <140/90 GFR <50: 33% had decrease in GFR
Jones and Hayslett13
Cr >1.9 mg/dL
12% on dialysis within 1 year of delivery
Imbasciati et al14
Nondiabetic renal disease
CrCl 35 mL/min
31% on dialysis at 37 months postpartum
Chopra et al56
Cr >1.5 mg/dL
29% had progression of disease
Abbreviations: Cr, creatinine; CrCl, creatinine clearance; ESRD, end stage renal disease; GFR, glomerular filtration rate.
preterm delivery, 40% will develop preeclampsia, and 40% will experience pregnancy or postpartum deterioration in renal function, leading to dialysis.13 Urine protein excretion may increase markedly in pregnant women with underlying renal disease—perhaps tripling from baseline—which may also adversely affect outcome. In one study of pregnant women with stage 3 to 5 kidney disease, the rate of decline in GFR accelerated in the subgroup with both estimated GFR of less than 40 mL/min and proteinuria greater than 1 g/d before pregnancy.14 The level of blood pressure at conception is an important variable in pregnancy outcome. In the absence of hypertension, there is significantly less chance of irreversible deterioration in renal function during pregnancy. When hypertension is present, pregnancy outcome is rarely uncomplicated. Preterm delivery and deterioration in renal function are expected. Finally, in patients with renal disease in whom eventual renal transplant is anticipated, pregnancy may result in immune sensitization, leading to difficulty locating a suitable matching donor. Renal Diseases Associated with Systemic Illness
Diabetes is one of the most common medical disorders of pregnancy, with most cases caused by gestational diabetes. Preexisting diabetes poses significant risks to pregnancy, and many women have type 1 diabetes; if their disease has been present for 10
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to 15 years, they may have diabetic nephropathy. Women with diabetes, microalbuminuria, well-preserved renal function, and normal blood pressure have a good prognosis for pregnancy, although they are at increased risk for preeclampsia and urinary infection.15,16 One prospective cohort study from Denmark followed-up 240 women who had type 1 diabetes during pregnancy, 11% of whom had microalbuminuria and 5% overt diabetic nephropathy. Of this cohort, 62% of women with microalbuminuria and normal renal function and 91% of women with overt diabetic nephropathy had preterm deliveries (compared with 35% of women with no albuminuria). Preeclampsia developed in 6% of women with no albuminuria compared with 42% and 64% of women with microalbuminuria and overt diabetic nephropathy, respectively.16 In another study of 72 pregnancies in 58 women with diabetic nephropathy, an elevated serum creatinine at enrollment was associated with preterm delivery, very low birth weight, and neonatal hypoglycemia, and was independent of urinary protein excretion. With respect to progression of maternal renal disease as a consequence of pregnancy, one study from Denmark reported that 26 women with type 1 diabetes who became pregnant had similar rates of deterioration in renal function over a 16-year follow-up compared with 67 control subjects with comparable disease who had never been pregnant.17 Thus, when baseline renal function and blood pressure are still normal, pregnancy is not likely to accelerate the progression of early diabetic nephropathy,17 although urinary protein excretion often increases significantly during pregnancy. Women with non–nephrotic range proteinuria preconception may develop nephrotic range proteinuria during pregnancy, which is usually reversible. Women with overt nephropathy preconception, particularly those with impaired renal function and hypertension, have a high incidence of preterm delivery, preeclampsia, and deterioration in maternal renal function.15 However, women with type 1 diabetes with microalbuminuria and normal renal function and normotension should be encouraged not to postpone pregnancy, because of the worse prognosis once overt nephropathy develops. Blood pressure control is important; however, because angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers are contraindicated during all three trimesters of pregnancy, and in the 2nd and 3rd trimesters carry a neonatal mortality rate of 25%, women should be switched to other agents that are safe to use in pregnancy, such as methyldopa, labetolol, or nifedipine, before conception. After delivery, if ACEIs are to be restarted and the patient wishes to breast-feed, enalapril has been deemed safe by the American Pediatrics Association; it is likely a class effect, but safety data are lacking in other ACEIs. No studies of pregnancy and nephropathy associated with type 2 diabetes have been published; however, given the increasing prevalence of this condition, it is an important area for future study. Lupus nephritis during pregnancy presents unique problems. Although similar considerations apply regarding level of renal function and blood pressure and their relationship to pregnancy outcome, generally lupus is a much more unpredictable illness because of the tendency of the disease to flare. Recent data suggest that pregnancy duration, total disease duration, and disease activity and damage before pregnancy are associated with increased organ damage after pregnancy in women with lupus.18 Whether pregnancy per se is a risk factor for lupus flares has been disputed. Although some experts report no increase in flares attributable to pregnancy in patients in remission, prospective data suggest that pregnancy is in fact associated with a greater chance of disease exacerbation.19 Women with lupus nephritis are advised not to conceive unless their disease has been inactive for the preceding
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6 months, because active disease is associated with a higher incidence of fetal demise. Disease is considered inactive when the creatinine measurement is less than 0.7 mg/dL or 62 mmol/L, proteinuria is less than 0.5 g/d, and, on spun urine examination, fewer than five red blood cells are present per high-powered field. Fetal loss occurs in 25% to 50% of women who conceive when their disease is active with a creatinine of greater than 1.2 mg/dL, or 106 mmol/L.20 Additional complications associated with lupus and pregnancy include placental transfer of maternal autoantibodies, which can cause a neonatal lupus syndrome characterized by heart block, transient cutaneous lesions, or both. Women with lupus are also more likely to have clinically significant titers of antiphospholipid antibodies (anticardiolipin, lupus anticoagulant), which are associated with spontaneous fetal loss of 50% to 75%, hypertensive syndromes indistinguishable from preeclampsia, and thrombotic events, including deep vein thrombosis, pulmonary embolus, myocardial infarction, and strokes.21 Thus, all women with systemic lupus erythematosus should be screened for antiphospholipid antibodies early in gestation. When titers are elevated (>40 GPL), daily aspirin (80–325 mg) is recommended. If the woman has a history of thrombotic events or pregnancy loss, then heparin in combination with aspirin is recommended. One difficulty in managing lupus nephritis during pregnancy is that increased activity of lupus may be difficult to distinguish from preeclampsia. Both are characterized by an increase in proteinuria, a decrease in GFR, and hypertension. Thrombocytopenia may also be observed in both conditions. Hypocomplementemia is not a feature of preeclampsia, whereas increases in liver function tests may be observed in preeclampsia but are not characteristic of lupus activity. If disease activity is present before 20 weeks of gestation, then the diagnosis is more likely to be a lupus flare. Spun urine microscopy for red blood cell casts can also signal lupus nephritis activity. In the latter half of pregnancy, a renal lupus flare may be impossible to distinguish from preeclampsia; frequently both are present simultaneously, and what starts as increased lupus activity seems to trigger preeclampsia. Unfortunately, delivery may be necessary if immunosuppressive therapy and supportive care fail to stabilize the condition. The approach to treating lupus nephritis during pregnancy is based largely on anecdotal experience, principles of treatment used in nonpregnant patients, and knowledge of fetal toxicity of immunosuppressants. Steroids and azathioprine are the mainstays of treatment. Hydroxychloroquine during pregnancy seems to be associated with improved outcomes and does not seem to be toxic to the fetus.22 Cyclophosphamide is generally not recommended during pregnancy because of potential fetal toxicity, and should only be used when the mother's life is in jeopardy. Mycophenolate mofetil should not be used during pregnancy to treat lupus nephritis because it is embryotoxic in animal studies, has been associated with fetal malformations in humans, and recent reports have characterized it as a teratogen.23 Chronic Glomerulonephritis
Childbearing women may be afflicted with any of the forms of chronic glomerulonephritis, including immunoglobulin A nephropathy, focal and segmental glomerulosclerosis, membranoproliferative glomerulonephritis, minimal change nephritis, and membranous nephropathy. The authors are unaware of data that would support the notion that histologic subtype confers a specific prognosis for pregnancy. Rather, the previously mentioned principles are applicable to women with chronic glomerulonephritis; baseline renal function and blood pressure are what dictate outcomes.
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Polycystic Kidney Disease
Young women with autosomal dominant polycystic kidney disease (ADPKD) are frequently asymptomatic, with normal renal function and normal blood pressure, and may be unaware of their diagnosis. Little has been written about polycystic kidney disease and pregnancy because many patients with this condition have wellpreserved renal function until after childbearing. A series involving 235 women with autosomal dominant polycystic kidney disease and 108 unaffected family members evaluated pregnancy outcomes reported an increased incidence of maternal complications in affected compared with unaffected women.24 Preexisting hypertension was the most common risk factor for maternal complications during pregnancy, because hypertension is a well-known risk factor for preeclampsia.24 Pregnant women with polycystic kidney disease should also be considered at increased risk for urinary tract infection. Estrogen is reported to cause liver cysts to enlarge, and repeated pregnancies may result in symptomatic enlargement of liver cysts. Given the association between cerebral aneurysms and ADPKD in some families, screening for these aneurysms should be considered before natural labor. All patients should undergo genetic counseling before pregnancy to ensure they are aware that their offspring have a 50% chance of being affected. Chronic Pyelonephritis
Chronic pyelonephritis is defined as nephropathies associated with recurrent urinary tract infection, often in association with urinary tract abnormalities (eg, vesicoureteral reflux). Chronic pyelonephritis caused by dilation and stasis in the urinary tract may exacerbate in pregnancy. Women with reflux nephropathy have been reported to have an adverse prognosis during pregnancy. A prospective study of 54 pregnancies in 46 women with reflux nephropathy found that preeclampsia was present in 24%, most commonly in women with preexisting hypertension.25 Deterioration in renal function during pregnancy occurred in 18%, and those with preexisting reduced renal function were at greater risk. One third of the infants were delivered preterm, and 43% had vesicoureteral reflux. These women should have a high fluid intake and be screened with urine cultures at least monthly for bacteriuria, and should be treated promptly when infections are present. In some cases, after a first infection, suppressive antibiotic therapy for the duration of pregnancy may be warranted. Chronic Renal Diseases That May be First Diagnosed During Pregnancy
The presence of chronic renal disease may first be appreciated during pregnancy partly because pregnant women are scrutinized more closely, and also because the renal hemodynamic alterations during pregnancy may cause proteinuria to increase and be clinically detectable for the first time. Frequent measurement of blood pressure may also lead to diagnosis of renal diseases accompanied by hypertension. Furthermore, the presence of even mild preexisting renal disease is associated with an increased risk for preeclampsia, and therefore underlying renal disease may first become apparent after preeclampsia has developed. Renal diseases that may have been silent preconception and may ''present'' during pregnancy include IgA nephropathy, focal and segmental glomerulosclerosis, polycystic kidney disease, and reflux nephropathy. Renal diagnostic testing during pregnancy can include blood and urine testing and ultrasonography. Renal biopsy is
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usually deferred until after delivery unless acute deterioration in renal function occurs26 or morbid nephrotic syndrome is present. Although experienced operators have reported few complications of renal biopsy during pregnancy, increased renal blood flow, hypertension, and difficulty positioning the patient are concerns.27–29 The timing of renal biopsy after delivery depends on the clinical circumstances. If renal function is normal, and only proteinuria is present, it is reasonable to delay biopsy up to 6 months postpartum, because proteinuria may improve once the pregnancy-associated hemodynamic alterations have resolved. However, if renal function is impaired, then biopsy may be considered within a few weeks of delivery. Renal Diseases That Develop for the First Time During Pregnancy
Pregnant women are at risk for any of the renal diseases that occur in women of childbearing age, including pyelonephritis, glomerulonephritis GN, interstitial nephritis, and acute renal failure. Pyelonephritis is more likely to be associated with significant azotemia in pregnant women than nonpregnant women, and should be treated aggressively. Glomerulonephritis and interstitial nephritis are not more likely to develop during pregnancy, although they do occur. Acute kidney injury in association with pregnancy is a rare complication in developed countries, and is also decreasing in incidence in the developing world, with only 190 cases observed in a 20-year period in Eastern India.30 Recent estimates suggest that the incidence of acute kidney injury from obstetric causes is less than 1 in 20,000 pregnancies.31 Treatment of acute glomerulonephritis presenting during pregnancy is challenging because immunosuppressants are toxic to the fetus, and high-dose steroids have not been studied during pregnancy. Acute glomerulonephritis presenting in pregnancy should be treated in close collaboration with the obstetrician and nephrologist. If acute renal deterioration is seen after 28 to 32 weeks gestation, the patient should probably be delivered and renal biopsy performed postpartum. When acute kidney injury occurs early in pregnancy (12–18 weeks), it is usually associated with septic abortion or prerenal azotemia caused by hyperemesis gravidarium. Most cases of acute kidney injury in pregnancy occur between gestational week 35 and the puerperium, and are primarily caused by preeclampsia and bleeding complications. Preeclampsia, particularly the HELLP variant (hemolysis, elevated liver enzymes, low platelet count), is an important cause of acute kidney injury in pregnancy.15 Although most cases of preeclampsia are not usually associated with renal failure, the HELLP syndrome may be associated with significant renal dysfunction, especially if not treated promptly with delivery. In rare instances, dialysis may be necessary, but most women without preexisting renal or hypertensive disease do not require long-term dialysis therapy. Additional important clinical entities causing acute kidney injury during pregnancy are discussed. Thrombotic Microangiopathy
Although rare, thrombotic microangiopathies (thrombotic thrombocytopenic purpura [TTP] and hemolytic uremic syndrome [HUS]) are an important cause of pregnancy-associated acute renal failure because they are associated with considerable morbidity. They also share several clinical and laboratory features of pregnancy-specific disorders, such as the HELLP variant of preeclampsia and acute fatty liver of pregnancy. Therefore, distinction of these syndromes is important for therapeutic and prognostic reasons. Features that may be helpful in making the correct diagnosis include timing of onset and the pattern of laboratory abnormalities. Preeclampsia typically develops in the
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third trimester, with only a few cases developing in the postpartum period, usually within a few days of delivery. TTP usually occurs antepartum, with many cases developing in the second and third trimesters. HUS is usually a postpartum disease; symptoms may begin antepartum, but most cases are diagnosed postpartum. Preeclampsia is much more common than TTP/HUS and is usually preceded by hypertension and proteinuria. Renal failure is unusual in women with preeclampsia, even in severe cases, unless significant bleeding or hemodynamic instability or marked disseminated intravascular coagulation occurs. In some cases, preeclampsia develops in the immediate postpartum period and, when thrombocytopenia is severe, it may be indistinguishable from HUS. However, preeclampsia spontaneously recovers, whereas TTP/HUS is often associated with persistent renal insufficiency and hypertension, with many requiring dialysis or transplantation long-term.32 In contrast to TTP/HUS, preeclampsia may be associated with mild disseminated intravascular coagulation and prolongation of prothrombin and partial thromboplastin times. Another laboratory feature of preeclampsia/HELLP syndrome that is not usually associated with TTP/HUS is marked elevations in liver enzymes. The presence of fever is more consistent with a diagnosis of TTP than preeclampsia or HUS. The main distinctive features of HUS are its tendency to occur in the postpartum period and the severity of the associated renal failure. Treatment of TTP/HUS includes plasma infusion/exchange and other modalities used in nonpregnant patients with these disorders. Treatment of preeclampsia/HELLP syndrome involves delivery and supportive care. More aggressive treatment is rarely indicated. Some centers have reported the use of steroids in cases of severe HELLP syndrome, although this therapy has not been rigorously evaluated in placebocontrolled clinical trials.33 Acute Tubular Necrosis
Acute tubular necrosis induced by volume depletion or exposure to nephrotoxins may occur during pregnancy, although the incidence is low. In the first trimester, acute tubular necrosis is usually associated with hyperemesis gravidarium, whereas later in pregnancy and in the peripartum period it is usually associated with abruptio placenta or other causes of obstetric hemorrhage. Occasionally, nonsteroidal anti-inflammatory agents, used for postpartum analgesia, may precipitate acute kidney injury in patients who are volume-depleted from hemorrhage, decreased fluid intake, or both. In severe cases of obstetric hemorrhage, acute cortical necrosis with associated disseminated intravascular coagulation may be present, and ultrasonography or computed tomography may demonstrate hyperechoic or hypodense areas in the renal cortex. These patients usually require dialysis, but 20% to 40% may have partial recovery of renal function. Acute Fatty Liver of Pregnancy
Acute fatty liver of pregnancy (AFLP) is a rare complication of late pregnancy characterized by rapidly progressive liver failure. Women usually present with nausea, vomiting, and anorexia, and many have clinical and laboratory features that overlap with preeclampsia or HELLP syndrome.34 Other laboratory abnormalities (in addition to marked elevations in alanine aminotransferase and aspartate aminotransferase) frequently observed include elevated bilirubin, hypofibrinogenemia, prolonged partial thromboplastin time, hypoglycemia, anemia, and low platelet count.35 Many cases are associated with significant azotemia, and one series comparing AFLP with HELLP syndrome observed that acute renal failure was significantly more common with AFLP.36 Because AFLP is believed to be a disease of mitochondrial dysfunction,37 the kidney dysfunction associated with AFLP may reflect inhibition of b-oxidation of fats in the
Management of Renal Disease in Pregnancy
kidney. This disease occurs in women heterozygous for long-chain 3-hydroxyacylcoenzyme A dehydrogenase (LCHAD) deficiency and whose fetus has the disorder. Abnormal fatty-acid metabolites produced by the fetus seem to enter the maternal circulation and overwhelm the mitochondrial-oxidation machinery of the heterozygous mother. Autopsy data have shown microvesicular fat in the kidneys of women with AFLP. Delivery is urgently required, and most patients improve shortly afterwards. This disorder was formerly associated with a more ominous outcome, which may have been a consequence of late diagnosis, although in a recent case series maternal mortality occurred in 2 of 6 women.35 When diagnosed early, long-term morbidity is reduced. Urinary Tract Obstruction
Pregnancy is associated with dilation of the collecting system, which is not usually accompanied by renal dysfunction. Rarely, complications such as large uterine fibroids that enlarge in the setting of pregnancy can lead to obstructive uropathy. Occasionally, acute urinary tract obstruction in pregnancy is caused by a kidney stone. Diagnosis can usually be made with ultrasonography. Often the stone will pass spontaneously, but occasionally cystoscopy is needed to insert a stent to remove a fragment of stone and relieve obstruction, particularly if sepsis or a solitary kidney is present. Extracorporeal shock wave lithotripsy is contraindicated during pregnancy because of the possibility of adverse effects on the fetus. Treatment of Acute Kidney Injury
Treatment of acute kidney injury occurring in pregnancy or immediately postpartum is similar to that in nongravid subjects, although several important considerations are unique to pregnancy. Uterine hemorrhage near term may be concealed and blood loss underestimated; thus, any overt blood loss should be replaced early. When dialysis is required, peritoneal dialysis and hemodialysis have been used successfully in patients with obstetric acute kidney injury. Neither pelvic peritonitis nor the enlarged uterus is a contraindication to the former method. In fact, this treatment is more gradual than hemodialysis and may be less likely to precipitate labor. Because urea, creatinine, and other metabolites that accumulate in uremia traverse the placenta, dialysis should be undertaken early, with the goal of maintaining the blood urea nitrogen at approximately 50 mg/dL (8 mmol/L). Excessive fluid removal should be avoided, because it may contribute to hemodynamic compromise, reduction of uteroplacental perfusion, and premature labor. However, polyhydramnios is a complication of a high maternal urea, leading to high urea and solute diuresis by the fetus, and is also believed to contribute to premature labor. When large volumes of ultrafiltration are required, continuous fetal monitoring during dialysis may be advisable, particularly after mid-pregnancy.
THERAPY FOR END-STAGE RENAL DISEASE DURING PREGNANCY Dialysis
Fertility is reduced in patients undergoing dialysis because of abnormalities of pituitary luteinizing hormone release leading to anovulation. Pregnancy that occurs in women undergoing maintenance dialysis is extremely high risk for the fetus, and conception should not be encouraged because of very high fetal mortality. Large surveys have shown that only 42% to 60% of these pregnancies result in a live-born infant. Preterm birth, very low birth weight, and intrauterine growth restriction are common, and more than 85% of infants born to women who conceive after starting dialysis are born before 36 weeks gestation.
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Management of pregnant patients on dialysis includes several considerations, but the single most important factor influencing fetal outcome is the maternal plasma urea level.38 In patients undergoing hemodialysis, the number of dialysis sessions per week must be increased and the session duration prolonged to a minimum of 20 h/wk, aiming for a predialysis urea of 30 to 50 mg/dL (5–8 mmol/L).38–40 In small series, daily nocturnal hemodialysis has also been used with success to this end.41 Heparinization should be minimal to prevent obstetric bleeding. Dialysate bicarbonate should be decreased to 25 mEq/L to target a predialysis bicarbonate level of approximately 22 mEq/L. If peritoneal dialysis is used, decreasing exchange volumes through increasing exchange frequency or cycler use is recommended.42 Adequate calorie and protein intake is required; 1 g per kilogram body weight per day of protein intake plus an additional 20 g/d has been suggested.43 After the first trimester, maternal ''dry'' weight should be increased by approximately 1 lb/wk (400 g/wk) to adjust for the expected progressive weight increase in pregnancy. Antihypertensive therapy should be adjusted for pregnancy by discontinuing ACEIs and angiotensin receptor blockers, and aiming to maintain maternal diastolic pressure at 80 to 90 mm Hg using methyldopa, labetolol, and sustained release nifedipine in standard doses to achieve target. Anemia should be treated with supplemental iron, folic acid, and erythropoietin. Erythropoietin is safe in pregnancy, and pregnancyrelated erythropoietin resistance requires a dose increase of approximately 50% to maintain hemoglobin target levels of 10 to 11 g/dL.39 Frequent monitoring of iron stores and treatment with intravenous iron should be prescribed as necessary.43 Because of placental 25-hydroxyvitamin D3 conversion, decreased supplemental vitamin D may be required and should be guided by levels of vitamin D, parathyroid hormone, calcium, and phosphorus. Sevelamer should not be used in pregnancy because animal studies have shown reduced or irregular ossification of fetal bones. Oral magnesium supplementation may be needed to maintain the serum magnesium level at 5 to 7 mg/dL (2–3 mmol/L), particularly because magnesium is a tocolytic, and low serum levels could theoretically promote uterine contractions. Based on a large meta-analysis, low-dose aspirin to prevent preeclampsia in women at risk for this complication may be advisable in those also on dialysis.44 Babies born to mothers on dialysis may require monitoring for osmotic diuresis in the immediate postpartum period if maternal urea was high at delivery. Anticonvulsant Therapy
The presence of dialysis or significant renal dysfunction, loading dose, and infusion rate of magnesium sulfate must be modified and monitored with serial magnesium levels, because doses will accumulate. Renal Transplantation
Josephson and McKay provide a more detailed discussion of renal transplantation in pregnancy elsewhere in this issue. However, a brief summary follows. Menstruation and fertility resumes in most women at 1 to 12 months post–renal transplant. Several thousand women have undergone pregnancy after renal transplantation, and pregnancy in this population seems to involve much lower risk to mother and baby than pregnancy in patients on dialysis. Although pregnancy has become common after transplantation, little other than case reports, series, and voluntary databases are available to guide practice. A Consensus Conference generated a report in 2005 summarizing the literature, produced practice guidelines, and identified gaps in knowledge.45 Most pregnancies (>90%) succeed that proceed beyond
Management of Renal Disease in Pregnancy
the first trimester; however, immunosuppressant effects, preexisting hypertension, and renal dysfunction cause maternal and fetal complications. Maternal complications of steroid therapy include impaired glucose tolerance, hypertension (47%–73%), preeclampsia (30%), and increased infection. Fetal complications include a 45% to 60% incidence of premature delivery (mean gestational age is 36 weeks) and intrauterine growth restriction with lower birth weight (average 2.3–2.6 kg). Best practice guidelines outline criteria for considering pregnancy in renal transplant recipients,45–47 and suggest that those contemplating pregnancy should meet the following: Good health and stable renal function for 1 to 2 years after transplantation with no recent acute or ongoing rejection or infections Absent or minimal proteinuria (<0.5 g/d) Normal blood pressure or easily managed hypertension No evidence of pelvicalcyceal distention on ultrasonography before conception Serum creatinine less than 1.5 mg/dL (133 mmol/L) Drug therapy: prednisone 15 mg/d or less; azathioprine 2 mg/kg or less; cyclosporine less than 5 mg/kg per day. Because of risk for intrauterine growth restriction and preeclampsia, all pregnant transplant recipients should be managed by a high-risk obstetrician. Future studies are required to address optimal immunosuppression in pregnancy. Although cyclosporine levels tend to decrease during pregnancy, no information is available on whether drug dosage should be increased. Experience with tacrolimus is increasing; although it has not been used as widely in pregnancy as cyclosporine, growing experience suggests that it is safe and has a similar side effect profile to cyclosporine.48 Considerations regarding hypertension and growth restriction are important; no established blood pressure target exists, although 130/80 mm Hg or less is suggested by the authors and Josephson and McKay in their article found elsewhere in this issue. Antihypertensives should be switched to those safe in pregnancy.49 Mycophenolate mofetil and sirolimus are not considered safe in pregnancy.50 Mycophenolate mofetil has been reported to be embryotoxic in animals, is associated with ear and other deformities in humans, and was recently characterized as a teratogen.23 This drug should be discontinued 6 weeks before conception, and women should be switched to azathioprine if indicated. Sirolimus causes delayed ossification in animal studies, and although successful live-born human outcomes have been reported, its use is contraindicated until more data are available. Finally, data from the National Transplantation Pregnancy Registry and European Dialysis and Transplant Association suggest that pregnancy rarely negatively affects the graft, although minor increases in serum creatinine may be seen postpartum compared with prepregnancy levels.46,50 A long-term analysis of parous compared with nulliparous women who underwent transplantation followed up for 20 years suggests that a live birth in women with a functioning graft does not have an adverse impact on graft and patient survival.51 Rejection is difficult to diagnose in pregnancy, and renal biopsy may be required; the consensus opinion is that steroids are safe treatment as is intravenous immunoglobulin, but the safety of antilymphocyte globulins and rituximab in pregnancy are unknown.45 SUMMARY
Although kidney disease in pregnancy is uncommon, it poses considerable risk to maternal and fetal health. Based on case series published over the past several decades, pregnancy outcome seems to be directly related to level of baseline renal
Podymow et al
function and degree of hypertension. Because these disorders are uncommon, multicenter efforts are needed to better identify risks and determine optimal therapeutic strategies. REFERENCES
1. Christensen T, Klebe JG, Bertelsen V, et al. Changes in renal volume during normal pregnancy. Acta Obstet Gynecol Scand 1989;68(6):541–3. 2. Ramin SM, Vidaeff AC, Yeomans ER, et al. Chronic renal disease in pregnancy. Obstet Gynecol 2006;108(6):1531–9. 3. Weissenbacher ER, Reisenberger K. Uncomplicated urinary tract infections in pregnant and non-pregnant women. Curr Opin Obstet Gynecol 1993;5(4): 513–6. 4. Sturgiss SN, Dunlop W, Davison JM. Renal haemodynamics and tubular function in human pregnancy. Baillieres Clin Obstet Gynaecol 1994;8(2):209–34. 5. Wolfe LA, Kemp JG, Heenan AP, et al. Acid-base regulation and control of ventilation in human pregnancy. Can J Physiol Pharmacol 1998;76(9):815–27. 6. Akbari A, Wilkes P, Lindheimer M, et al. Reference intervals for anion gap and strong ion difference in pregnancy: a pilot study. Hypertens Pregnancy 2007; 26(1):111–9. 7. Davison JM, Sheills EA, Philips PR, et al. Metabolic clearance of vasopressin and an analogue resistant to vasopressinase in human pregnancy. Am J Physiol 1993; 264(2 Pt 2):F348–53. 8. Danielson LA, Conrad KP. Time course and dose response of relaxin-mediated renal vasodilation, hyperfiltration, and changes in plasma osmolality in conscious rats. J Appl Physiol 2003;95(4):1509–14. 9. Girling JC. Re-evaluation of plasma creatinine concentration in normal pregnancy. J Obstet Gynaecol 2000;20(2):128–31. 10. Akbari A, Lepage N, Keely E, et al. Cystatin-C and beta trace protein as markers of renal function in pregnancy. BJOG 2005;112(5):575–8. 11. Phelan LK, Brown MA, Davis GK, et al. A prospective study of the impact of automated dipstick urinalysis on the diagnosis of preeclampsia. Hypertens Pregnancy 2004;23(2):135–42. 12. Cote AM, Brown MA, Lam E, et al. Diagnostic accuracy of urinary spot protein:creatinine ratio for proteinuria in hypertensive pregnant women: systematic review. BMJ 2008;336(7651):1003–6. 13. Jones DC, Hayslett JP. Outcome of pregnancy in women with moderate or severe renal insufficiency. N Engl J Med 1996;335(4):226–32. 14. Imbasciati E, Gregorini G, Cabiddu G, et al. Pregnancy in CKD stages 3 to 5: fetal and maternal outcomes. Am J Kidney Dis 2007;49(6):753–62. 15. Khoury JC, Miodovnik M, LeMasters G, et al. Pregnancy outcome and progression of diabetic nephropathy. What's next? J Matern Fetal Neonatal Med 2002; 11(4):238–44. 16. Ekbom P, Damm P, Feldt-Rasmussen B, et al. Pregnancy outcome in type 1 diabetic women with microalbuminuria. Diabetes Care 2001;24(10):1739–44. 17. Rossing K, Jacobsen P, Hommel E, et al. Pregnancy and progression of diabetic nephropathy. Diabetologia 2002;45(1):36–41. 18. Andrade RM, McGwin G Jr, Alarcon GS, et al. Predictors of post-partum damage accrual in systemic lupus erythematosus: data from LUMINA, a multiethnic US cohort (XXXVIII). Rheumatology (Oxford) 2006;45(11):1380–4.
Management of Renal Disease in Pregnancy
19. Ruiz-Irastorza G, Lima F, Alves J, et al. Increased rate of lupus flare during pregnancy and the puerperium: a prospective study of 78 pregnancies. Br J Rheumatol 1996;35(2):133–8. 20. Rahman FZ, Rahman J, Al-Suleiman SA, et al. Pregnancy outcome in lupus nephropathy. Arch Gynecol Obstet 2005;271(3):222–6. 21. Erkan D. The relation between antiphospholipid syndrome-related pregnancy morbidity and non-gravid vascular thrombosis: a review of the literature and management strategies. Curr Rheumatol Rep 2002;4(5):379–86. 22. Clowse ME, Magder L, Witter F, et al. Hydroxychloroquine in lupus pregnancy. Arthritis Rheum 2006;54(11):3640–7. 23. Anderka MT, Lin AE, Abuelo DN, et al. Reviewing the evidence for mycophenolate mofetil as a new teratogen: case report and review of the literature. Am J Med Genet A 2009;149A(6):1241–8. 24. Chapman AB, Johnson AM, Gabow PA. Pregnancy outcome and its relationship to progression of renal failure in autosomal dominant polycystic kidney disease. J Am Soc Nephrol 1994;5(5):1178–85. 25. North RA, Taylor RS, Gunn TR. Pregnancy outcome in women with reflux nephropathy and the inheritance of vesico-ureteric reflux. Aust N Z J Obstet Gynaecol 2000;40(3):280–5. 26. Day C, Hewins P, Hildebrand S, et al. The role of renal biopsy in women with kidney disease identified in pregnancy. Nephrol Dial Transplant 2008;23(1): 201–6. 27. Packham D, Fairley KF. Renal biopsy: indications and complications in pregnancy. Br J Obstet Gynaecol 1987;94(10):935–9. 28. Chen HH, Lin HC, Yeh JC, et al. Renal biopsy in pregnancies complicated by undetermined renal disease. Acta Obstet Gynecol Scand 2001;80(10):888–93. 29. Kuller JA, D'Andrea NM, McMahon MJ. Renal biopsy and pregnancy. Am J Obstet Gynecol 2001;184(6):1093–6. 30. Prakash J, Kumar H, Sinha DK, et al. Acute renal failure in pregnancy in a developing country: twenty years of experience. Ren Fail 2006;28(4):309–13. 31. Gammill HS, Jeyabalan A. Acute renal failure in pregnancy. Crit Care Med 2005; 33(10 Suppl):S372–84. 32. Dashe JS, Ramin SM, Cunningham FG. The long-term consequences of thrombotic microangiopathy (thrombotic thrombocytopenic purpura and hemolytic uremic syndrome) in pregnancy. Obstet Gynecol 1998;91(5 Pt 1):662–8. 33. van Runnard Heimel PJ, Franx A, Schobben AF, et al. Corticosteroids, pregnancy, and HELLP syndrome: a review. Obstet Gynecol Surv 2005;60(1):57–70 [quiz: 73–4]. 34. Castro MA, Fassett MJ, Reynolds TB, et al. Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases. Am J Obstet Gynecol 1999; 181(2):389–95. 35. Fesenmeier MF, Coppage KH, Lambers DS, et al. Acute fatty liver of pregnancy in 3 tertiary care centers. Am J Obstet Gynecol 2005;192(5):1416–9. 36. Vigil-De Gracia P. Acute fatty liver and HELLP syndrome: two distinct pregnancy disorders. Int J Gynaecol Obstet 2001;73(3):215–20. 37. Ibdah JA, Bennett MJ, Rinaldo P, et al. A fetal fatty-acid oxidation disorder as a cause of liver disease in pregnant women. N Engl J Med 1999;340(22): 1723–31. 38. Haase M, Morgera S, Budde K. A systematic approach to managing pregnant dialysis patients–the importance of an intensified haemodiafiltration protocol. Nephrol Dial Transplant 2005;20:2537–42.
Podymow et al
39. Asamiya Y, Otsubo S, Matsuda Y, et al. The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int 2009;75(11):1217–22. 40. Shemin D. Dialysis in pregnant women with chronic kidney disease. Semin Dial 2003;16(5):379–83. 41. Barua M, Hladunewich M, Keunen J, et al. Successful pregnancies on nocturnal home hemodialysis. Clin J Am Soc Nephrol 2008;3(2):392–6. 42. Smith WT, Darbari S, Kwan M, et al. Pregnancy in peritoneal dialysis: a case report and review of adequacy and outcomes. Int Urol Nephrol 2005;37(1): 145–51. 43. Holley JL, Reddy SS. Pregnancy in dialysis patients: a review of outcomes, complications, and management. Semin Dial 2003;16(5):384–8. 44. Askie LM, Duley L, Henderson-Smart DJ, et al. Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual patient data. Lancet 2007; 369(9575):1791–8. 45. McKay DB, Josephson MA, Armenti VT, et al. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005;5(7):1592–9. 46. EBPG Expert Group on Renal Transplantation. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.10. Pregnancy in renal transplant recipients. Nephrol Dial Transplant 2002;17(Suppl 4):50–5. 47. McKay DB, Josephson MA. Pregnancy in recipients of solid organs–effects on mother and child. N Engl J Med 2006;354(12):1281–93. 48. Kainz A, Harabacz I, Cowlrick IS, et al. Review of the course and outcome of 100 pregnancies in 84 women treated with tacrolimus. Transplantation 2000;70(12): 1718–21. 49. Podymow T, August P. Update on the use of antihypertensive drugs in pregnancy. Hypertension 2008;51(4):960–9. 50. Armenti VT, Radomski JS, Moritz MJ, et al. Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transpl 2004;103–14. 51. Levidiotis V, Chang S, McDonald S. Pregnancy and maternal outcomes among kidney transplant recipients. J Am Soc Nephrol 2009;20(11):2433–40. 52. Katz AI, Davison JM, Hayslett JP, et al. Pregnancy in women with kidney disease. Kidney Int 1980;18(2):192–206. 53. Abe S, Amagasaki Y, Konishi K, et al. The influence of antecedent renal disease on pregnancy. Am J Obstet Gynecol 1985;153(5):508–14. 54. Jungers P, Houillier P, Forget D, et al. Influence of pregnancy on the course of primary chronic glomerulonephritis. Lancet 1995;346(8983):1122–4. 55. Abe S. Pregnancy in IgA nephropathy. Kidney Int 1991;40(6):1098–102. 56. Chopra S, Suri V, Aggarwal N, et al. Pregnancy in chronic renal insufficiency: single centre experience from North India. Arch Gynecol Obstet 2009;279(5): 691–5.


text:
Magee, Mississippi
|This article needs additional citations for verification. (July 2016) (Learn how and when to remove this template message)
|Magee, Mississippi
Downtown Magee, Mississippi in March 2013.
Location of Magee, Mississippi
|Coordinates: 31°52′22″N 89°44′1″W / 31.87278°N 89.73361°WCoordinates: 31°52′22″N 89°44′1″W / 31.87278°N 89.73361°W
|United States
|February 25, 1900
|• Mayor
|Jimmy Clyde[1]
|• Total
|4.9 sq mi (12.6 km2)
|• Land
|4.9 sq mi (12.6 km2)
|• Water
|0.0 sq mi (0.0 km2)
|433 ft (132 m)
|Population (2000)
|• Total
|• Density
|860.5/sq mi (332.2/km2)
|Time zone
|Central (CST) (UTC−6)
|• Summer (DST)
|ZIP code
|Area code(s)
|FIPS code
|GNIS feature ID
Magee is a city in Simpson County, Mississippi, United States. The population was estimated to be near 5,019 as of February 2007. It is part of the Jackson Metropolitan Statistical Area.
The first white settlers in the area were Arthur Mangum and Phil Magee, both of whom entered the area around 1820. Pioneers from Virginia and the Carolinas followed. The town of Magee was once named Mangum, named after Arthur Mangum and it was named Mangum until 1859.[2][3] In 1840, Willis Magee built a grist mill on Little Goodwater Creek, inside the present city limits. On February 25, 1900, the community was incorporated as a village, with a population of 685 in 1910.[citation needed] The Magee Public School mascot is the Trojan.[4] Magee's zip code is 39111.[5]
Windham's Restaurant is located in Magee, locally known as "Zip's". In 2015, it was voted as serving the best hamburger in Mississippi.[6]
According to the United States Census Bureau, the city has a total area of 4.9 square miles (13 km2), all land. Magee is located between Jackson and Hattiesburg on U.S. Highway 49 at the intersection of three Mississippi Highways: 541, 545, and 28.
Magee has a humid subtropical climate, with an annual mean temperature 65.8 degrees and average annual rainfall of 56.9 inches (1,450 mm).
March 2009 tornado[edit]
On March 26, 2009, around 1:30 a.m., an EF3 tornado struck the north part of the city. The tornado destroyed 60 homes and 25 injuries occurred, with no fatalities. The tornado significantly damaged the town's water treatment plant, interrupting service to the entire town. Circuit Riders and other technicians from the Mississippi Rural Water Association worked with the city staff, local contractors and the Mississippi Emergency Management Agency to restore water service.[7] Using four MEMA generators, the rural water staff was able to restore service to Magee by 2:20 p.m. the next day.
|Historical population
|Est. {{{estyear}}}
As of the census[10] of 2000, there were 4,200 people, 1,573 households, and 984 families residing in the city. The population density was 860.5 people per square mile (332.3/km2). There were 1,725 housing units at an average density of 353.4 per square mile (136.5/km2). The racial makeup of the city was 62.67% White, 33.88% African American, 0.07% Native American, 0.26% Asian, 2.31% from other races, and 0.81% from two or more races. Hispanic or Latino of any race were 3.62% of the population.
There were 1,573 households out of which 29.9% had children under the age of 18 living with them, 39.6% were married couples living together, 18.8% had a female householder with no husband present, and 37.4% were non-families. 33.4% of all households were made up of individuals and 14.9% had someone living alone who was 65 years of age or older. The average household size was 2.37 and the average family size was 3.02.
In the city the population was spread out with 27.7% under the age of 18, 9.9% from 18 to 24, 26.3% from 25 to 44, 19.2% from 45 to 64, and 16.8% who were 65 years of age or older. The median age was 34 years. For every 100 females there were 93.5 males. For every 100 females age 18 and over, there were 83.8 males.
The median income for a household in the city was $20,779, and the median income for a family was $24,176. Males had a median income of $23,690 versus $16,767 for females. The per capita income for the city was $11,257. About 24.6% of families and 28.4% of the population were below the poverty line, including 42.9% of those under age 18 and 17.0% of those age 65 or over.
Prominent area industries include Tyson Foods, Polk's Meat Products, Real Pure Beverage Group, Howard Industry and Quality Foods.
The Simpson County Development Foundation Industrial Park is an ultramodern, 205-acre (0.83 km2) industrial park located on four-lane Highway 49. Rail services are available through Canadian National Railway. There is an abundant water supply and an Entergy substation providing ample electrical service to the park. Magee Industrial Park in South Magee offers similar facilities.[citation needed]
Arts and culture[edit]
Magee has a modern auditorium and local arts group include Artists Mississippi, the Simpson County Arts Council, and the Lamplight Theatre.
The Chamber of Commerce sponsors the annual Homecoming, the Christmas Parade, tree lighting and caroling.
Crazy Day comes once a year located on main street in Magee. It usually comes the third Saturday of the month September. Many locals go there to set up booths to sell homemade goods. Crazy day is all about people coming together and having a good time.
A new modern Civic Center provides space for meetings for civic clubs and other organizations and houses the Magee Chamber of Commerce office. The Civic Center has complete modern kitchen facilities and was built by the city with financial help from various individuals and organizations.
Magee Public Library, the first public library in Magee, was established in 1935 through the interest of business and professional people in the town. Mrs. Maude Turner was librarian. In 1937, the library was named Mims Williams Memorial Library. The library is now a member of the Central Mississippi Regional Library System. The new library was built in 1975. It is staffed by two full-time workers and one part-time worker. The Old Magee Cemetery is the burial place of some of Magee's earliest settlers.
The Sanatorium Museum, a museum of memorabilia from the old tuberculosis hospital, includes the old telephone switchboard, a patient bedroom with nightstand, equipment and many photographs, located on Highway 49 North two miles (3 km) north of Magee, in Sanatorium, Mississippi.[citation needed]
The City of Magee is served by the Simpson County School District.
Public schools[edit]
- Magee High School
- Magee Middle School
- Magee Elementary
Higher learning[edit]
A branch of Copiah-Lincoln Community College is located in Magee.
The Magee Courier and Simpson County News serve the town.
Magee is home to a 50,000 Watt AM radio station, WSJC on 810 kHz. WKXI, a 100,000 Watt FM radio station on 107.5 and WRBJ-TV, a television station operating on channel 34, are also legally licensed to Magee, but serve Jackson and have no presence in Magee.
FM radio[edit]
- WKXI 107.5 (Urban Adult Contemporary)
- WSMP-LP 96.9 (Church Alive, Inc)
AM radio[edit]
- WSJC 810 (Talk radio)
- Highways: U.S. Hwy 49; State Highways 28, 545, and 541.
- Railroad: Canadian National Railway (formally Illinois Central) serves the Magee area.
- Bus Lines: Greyhound Bus serves the area.
- Airport: The Magee Municipal Airport (FAA identifier 17M) is located three miles west of Magee. It maintains a lighted 3,104 ft (946 m) × 50 ft (15 m) runway and is attended 24 hours a day. There is a hangar, lobby and office building complex (no control tower). The complex is equipped with automatic dusk to dawn lights, a beacon, and a wind directional device.
Health care[edit]
Magee General Hospital is a modern 64-bed facility with Swing Bed capability. The hospital also has modern delivery suites with a newborn nursery. On staff are a number of specialists. The Radiology department features a CAT scanner, Nuclear Medicine and Ultrasound. The laboratory features the latest technology in computerized diagnostic equipment. The hospital offers 24-hour emergency services.[citation needed]
Magee Medical & Surgical clinic located adjacent to the hospital has five family practitioners. This building also houses the hospital's physical therapy department. Five dentists have practices in Magee. Other facilities include Hillcrest Health Center, Boswell Regional Center for adult persons with developmental disabilities, and Millcreek Rehabilitation Center, a private residential center for mental, emotionally and physically handicapped. Five Home Health Agencies serve the area. Magee also has one fully licensed 12-bed assisted living facility.[citation needed]
Public services[edit]
A new city hall, police station and city jail has been completed.
There are 16 full-time police personnel, including the Chief of Police and 12 auxiliary officers.
Magee has 36 trained volunteer firemen and 1 full-time Fire Marshall, 4 class A pumpers, 1 class A pumper/tanker, 1 Ladder Truck, one rescue unit and two utility trucks.
EMS is provided by American Medical Response.
In the Magee, Mississippi National Guard Unit, there are 149 members with five full-time personnel.
Notable people[edit]
- Kris Mangum, professional football player
- John Mangum, professional football player
- Roland Dale, professional football player
- Edgar Hardy, professional football player[11]
- Charley Williams, professional football player[12]
- Terrill Shaw, professional football player
- Harold Shaw, professional football player
- Justin Griffith, professional football player
- David Myers, politician[citation needed]
- Joseph Warren, politician[citation needed]
- Dan Monroe Russell Jr., United States federal judge
- Prentiss Walker, farmer, businessman and politician
- ^ "Our City Welcomes You". City Of Magee. Retrieved July 2016. Check date values in:
- ^ "http://freepages.genealogy.rootsweb.ancestry.com/~eastozarka/mangum/magg07.htm". External link in
- ^ http://freepages.genealogy.rootsweb.ancestry.com/~eastozarka/mangum/magg07.htm. Missing or empty
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- ^ http://www.maxpreps.com/high-schools/magee-trojans-(magee,ms)/home.htm. Missing or empty
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- ^ http://www.zip-codes.com/zip-code/39111/zip-code-39111.asp. Missing or empty
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- ^ "Zip Burger in Magee Named Best Burger in Mississippi". Eat, Drink, Mississippi. Retrieved July 2016. Check date values in:
- ^ "Rural Water assists Mississippi town after tornado". National Rural Water Association. 2009. Retrieved 2009-07-08.
- ^ "Annual Estimates of the Resident Population for Incorporated Places: April 1, 2010 to July 1, 2015". Retrieved July 2, 2016.
- ^ "Census of Population and Housing". Census.gov. Retrieved June 4, 2015.
- ^ "American FactFinder". United States Census Bureau. Retrieved 2008-01-31.
- ^ http://www.databasefootball.com/players/playerpage.htm?ilkid=HARDYED01. Missing or empty
|title=(help); External link in
- ^ http://www.databasefootball.com/players/playerpage.htm?ilkid=WILLICHA01. Missing or empty
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subset: commoncrawl


text:
WALNUT CREEK, Calif. -- The Oakland, Calif., apartment of Martha Mueller and her daughter, Nora, teems with books and magazines. Their library consists of fiction and nonfiction books, cookbooks and teen novels. Martha, a librarian, says she'll read just about anything.
"It can be the subject matter that attracts me or that perfectly written first sentence," she says.
She comprehends what she reads, too. Ask for her thoughts on the "Millennium Trilogy" by Swedish writer Stieg Larsson, for example, and she'll weave a tale about how the books, while interesting reads, seem overly violent. The main character is a victim, she says, and a sad one at that.
While Mueller loves sitting down with a good book, she may represent a vanishing breed. There is some concern in literary circles that, even though electronic readers grow increasingly popular and book sales are still strong, many people are finding it difficult to sit alone with one book and simply read to comprehend.
"Deep reading," or slow reading, is a sophisticated process in which people can critically think, reflect and understand the words they are looking at. With most, that means slowing down -- even stopping and rereading a page or paragraph if it doesn't sink in -- to really capture what the author is trying to say. Experts warn that without reading and really understanding what's being said, it is impossible to be an educated citizen of the world, a knowledgeable voter or even an imaginative thinker.
The concern that deep reading is going by the wayside is a phenomenon that author Nicholas Carr says in his book, "The Shallows: What the Internet is Doing to Our Brains," may have something to do with our use of technology and our habits while browsing the Web.
Just last summer, Google CEO Eric Schmidt said he was concerned about what he sees as a decline in slow reading. Instant messages and 140-character tweets appear to be taking over our ability to concentrate on a single idea or theme in a book, he told Foreign Policy Magazine.
It's easy to forget the benefits of deep reading in an age where anything worth doing is done fast, Canadian author John Miedema says. We surf the Internet, gather snippets of information and click hyperlinks that bring us to different topics and authors, he says. In less than a second, we can go from reading about Beethoven the composer to watching a clip about Beethoven the St. Bernard online.
"The Web is essentially a distraction machine," Miedema says. "Hyperlinks are meant to take you away from where you are."
In his book "Slow Reading," Miedema argues that deep reading is like the slow food movement -- it takes time, care and effort to read quietly and concentrate.
"I can appreciate people's desire to read faster," Miedema says. "But if you want to have a deep relationship with a text and understand a complex idea, then slow reading is a preferred style. It's good for pleasure, too. It's not a rushed experience and you can lose yourself in a text."
Mirit Barzillai, a child-development doctoral candidate at Tufts University of Boston, focuses on literacy and says researchers are just starting to study how people process what they read on websites.
"There are so many different and new places to read these days -- online, with electronic readers, on the phone -- that there isn't a lot of research looking at the processes of reading and how technology affects it," Barzillai says.
Barzillai is interested in the way children read and if they will learn how to read deeply as they grow up in the digital age.
"Reading isn't something we're born with," she says. "Your brain has to form that reading circuit. And that circuit is shaped by what you're reading. When (adults) came to the Internet, we came with those skills and experiences that were already developed. If children learn to read primarily online and through digital media, I wonder if we are encouraging or growing a different kind of reading process."
Nora Mueller, 17, notices that when she has to do a paper for school and researches it on the Internet, she rarely reads a whole page. She primarily clicks links and scans.
"I read so little about what's actually there. I don't feel like I absorb everything," Mueller says. "I'll read the beginning of a paragraph and then I'll skip the rest."
She can remember what she reads when she's engaged in a book, she says, but retains little from the Internet.
Ohlone College English professor Cynthia Lee Katona wrote "Book Savvy" specifically to help people who have stopped reading get back into it.
Katona was late in picking up her first book -- she didn't start reading novels until she was 14 -- but she's a voracious reader today. She says reading is a highly social activity that builds the mind and social connections. If you read, she says, you simply know more and have more to talk about with friends, partners and acquaintances.
Deep reading also can take readers on trips around the world even if they are sitting in a living room armchair, Katona says. Also, it helps readers understand themselves and others and develop thinking, writing and conversational skills.
"If you like beautiful things, authors put words together that are really beautiful and expressive," she says. "If you want to write well -- and there are lots of reasons to be articulate and to express yourself clearly -- you should read."


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One MP3 player? Not for R&B singer Ledisi.
Digital music appeals to her, Ledisi says, because of the "crystal-clear sound." Also, she likes the versatility and portability of her players, which can be used for music, movies, videos and audiobooks.
"You can just clip it on, and you're cool," she says. "It calms me when I'm in the airport and the flight isn't on time, or something. It blocks out the rest of the noise and the babies screaming. I've been a gypsy, lately, and been to St. Lucia, Miami, all over the Caribbean and Aruba."
Travel is a given when a performer's career is heating up, and Ledisi certainly qualifies in that category.
The New Orleans native received two Grammy nominations this year -- for best new artist and for her CD "Lost & Found" -- and appeared in the George Clooney-Renee Zellweger film "Leatherheads."
Ledisi also placed a song, "Alright," on the soundtrack of "Tyler Perry's Meet the Browns."
But she's faced her share of adversity. Her first group, Anibade, was formed in 1990 and did fairly well on the San Francisco nightclub scene. But they failed to interest a major label.
Anibade's first disc, "Soulsinger" (2000) was independently released. So was its follow-up, "Feeling Orange But Sometimes Blue" (2002).
Ledisi's first real break came in 2004 after she covered "My Sensitivity (Gets in the Way)" on "Forever, For Always, For Luther," a tribute disc devoted to the late Luther Vandross. She later moved to New York City and participated in a workshop production of Broadway's "The Color Purple." Ledisi also understudied in Tony Kushner's "Caroline, or Change."
When Verve Records came calling, Ledisi was ready for the leap, co-producing "Lost & Found" with Collin Stanback. She's been compared to some of her idols since then -- including Chaka Khan and Ella Fitzgerald -- and will make her City Stages debut June 13 on the Coca-Cola Classic Stage.
1. Miles Davis, "Kind of Blue," 1959 -- "It's calming and keeps me still. There's not a whole bunch of loudness to it. I just love Miles. His music sounds like painting; you can see the colors."
2. Abbey Lincoln, "A Turtle's Dream," 1995 -- "I love this because it does the same things Miles does. She's a beautiful singer, and she works like a poet. I especially love the song 'Throw It Away.' When I'm distressed or in any kind of pain, it tells me to just to throw it all away."
3. A Tribe Called Quest, "The Anthology," 1999 -- "It has great beats and love messages behind them. It's old-school hip-hop. I love the jazz samples and the Big Band sound in there. It's very complicated music, but simple to me. It makes sense and talks about everyday stuff. It's introspective, stuff to make me think."
4. Aretha Franklin, "30 Greatest Hits," 1990 -- "I love everything in there. I love Aretha; she relates to women, and she is a mack mama. I love being reminded of greatness, and that's what she is. This (collection) is an embodiment of a work that's timeless. All of the songs were written to fit her, and if they weren't, she'll take a song and make it her own."
5. Don Miguel Ruiz, "The Four Agreements: A Practical Guide to Personal Freedom" audio CD, 2003 -- "This is one of my favorite things of all time. I kept giving the book away, and then I wouldn't have it. I must have given away over 400 copies of that book. It tells me not to dwell on the past, to forgive, to be impeccable with my words, to think before I act, not to take things personally. I associate that whole book to everything I do."


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The sports car bears still have asomewhat crude name, even though the athlete crouches as flat as thelegendary M1 on the asphalt, probably ends with "e" ratherthan "M" starts,but it can already be assumed that He willmake the saving EfficientDynamics philosophy as a model from Munichever.
BMW says yes. The 163 hp 1.5-literpayable, three-cylinder diesel saved - Eco-classical three-set: fewercylinders and less friction, less fuel consumption. The two electricmotors (one front, one rear) anyway. The overall performance of thecombined sparkled with a six-speed dual-clutch gearbox drive amountsto 328 hp. The engines at the beginning for about three months in thebody of a BMW 6 Series were run walk are intelligently linked. Duringbraking, the Bayer wins back power, he can at home as a plug-inhybrid included in the standard (charging time: 2 1 / 2 hours).
Is driven purely electric (98lithium-polymer batteries are located where the conventionalrear-wheel drive vehicle in Kardan runs) the only extends for 50 km,the diesel engine gets into the business of transportation with one,comes the 2 +2 - after the paper - about 700 kilometers.
The vision becomes reality. Thedeep concept car only 1.24 m, 1.90 m wide and about 4.60 m longsports car goes, the outfit and the dimensions of the stringentrequirements of the adjusted series, the end of 2013 production.


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Blue Springs authorities said a missing a 68-year-old man has been found safe.
No other details were given.
Blue Springs police issued a Silver Alert Monday for Gerald V. Smith, who suffers dementia. He was reported missing on Dec. 8. Police said officers were called to his home to check on him and found the front open and his car gone.


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Guest Voice of Kyle Foust: Why I voted 'yes' for hotel
As an elected official, I'm going to back any initiative that will boost our economy. From my point of view, Erie County Council's 4-2 vote on Tuesday to guarantee a loan for a new hotel adjacent to the Bayfront Convention Center does that.
Through this process, I have listened to public input at public meetings, I have answered questions in stores, bars, school events and on Facebook, I have returned every phone call that asked for follow-up, and I have responded to countless e-mails to express my views and why I intend to vote as I did, in favor of the guarantee.
The job of an elected official is to vote, as informatively as he or she can, on the issues on behalf of the public. This is my rationale for supporting the hotel guarantee.
The Convention Center, not Erie County government, will issue the bond to build the hotel. Erie County is being asked to guarantee that bond; the guarantee will have the effect of saving $19 million over the life of the bond. The county will not own the land nor will it use property tax dollars to subsidize the operations of the hotel or Convention Center. The county's debt will not increase.
Infrastructure gets boost
The project will received a $25 million grant from the state (which means some of our state taxes are being returned to this community for the benefit of this community). If the grant isn't utilized for the intended purpose, the Convention Center will have to send it back, and it will be reallocated elsewhere in Pennsylvania. If we don't utilize the grant, I also believe we will put into jeopardy the city of Erie's request for $12 million for the same pool of money on behalf of the Scott Enterprises to develop the east side of State Street. The same scenario would go for the City Revitalization and Improvement Zone designation being sought from the state to develop the bayfront.
The bond savings that Erie County Council helped create will be reinvested by the Convention Center Authority into the former GAF Materials Corp. site so that proper infrastructure can be put into place to attract private investment there. No private developer will build anything on the GAF site without infrastructure in place, and no private developer is going to pay for those infrastructure improvements.
The proceeds from the operation of the hotels are dedicated to retiring the bond debt so the county's guarantee won't be called.
The hotel is also being built on Erie-Western Pennsylvania Port Authority land that currently is nontaxable and, because it's a parking lot, that won't change. However, by placing the hotel at the proposed site, it frees up more space on the GAF site for future private investment that can generate property taxes.
The purpose of the entire Convention Center complex is to drive convention and meeting business to that site. That requires marketing the facility and making it attractive enough for people to come here. To attract such business, a significant number of hotel rooms must be within or adjacent to the Convention Center. If not, groups won't even consider you.
The Sheraton Erie Bayfront Hotel is sufficient to attract certain groups, but its price is too high for many social, fraternal, military and religious groups. The new hotel, a Courtyard by Marriott, will now provide a more affordable option for certain groups and offer the opportunity to attract larger conventions.
Hotel demand exists
The market analysis completed by the Convention Center Authority's consultant, HVS, shows there is more than enough demand for not only the new hotel to survive but for the other hotels in the area to survive as well. I read the analysis, and I also talked to HVS consultants directly to ask pointed questions. In addition, the analysis HVS used is based on the same assumptions and rationale that the study for the original hotel used; that original study has proved to be very accurate. All financial projections for the Convention Center have been met, and the projections for the hotel have been exceeded (despite having to weather a recession that was not occurring when the idea was conceived).
While it may not seem like a long distance to us because we live here, Scott Enterprises' property on the east side of State Street is far enough away that it couldn't be marketed as one of the host hotels for a convention.
No convention takes all the rooms in a hotel. The hotel reserves rooms for travelers, business travelers, etc. and doesn't want to turn those people away, plus some conventioneers are price-sensitive and will stay at a more affordable place even if the Sheraton is available. Therefore, other hotels in the area benefit from that overflow effect. That is where the Scott property and other private entities will benefit.
By way of example, since 2008 and through events already booked through 2017, there have been 155 conventions or large meetings/events at the Convention Center; 79 of those required the use of other hotels in the area in addition to the Sheraton.
The Convention Center and adjacent hotel, although they are public entities, have had the effect of complementing and benefiting private industry. That, I believe, will continue and expand in the future if another hotel is built.
If Nick Scott Sr. builds his proposed project, I don't believe that will detract from what the Convention Center has done or will do. A larger critical mass of rooms on the bayfront will only allow the Convention Center to attract large and/or more diverse convention and meeting groups.
Community benefits
As evidence that the Convention Center and hotel have been economically good for the community, I will offer the following. Since the convention center complex has broken ground, more than 1,000 new hotel rooms (in addition to the Sheraton) have been built in Erie County to capture the demand for hotel rooms in the Erie area. That demand has increased, in part, because of convention/meeting business. Many restaurants, bars, amusement operations, etc., have either been built or expanded since the Bayfront Convention Center complex started operating. I know of no business that has closed whose loss can be solely blamed on the Convention Center. On the whole, it's been an overwhelming success.
For the first hotel vote nine years ago, I voted "yes" because I was confident the project would bring more people to Erie and that it would attract people to Erie who wouldn't come otherwise.
I also believed those events would be large enough to benefit other hoteliers. All of those conditions have been met. All financial projections have been met or exceeded. No local, Erie County tax dollars have been used on the project. I don't anticipate any will be used if another hotel is built.
In the end, it's unfortunate that bayfront development has been portrayed as an us-versus-them or private-versus-public proposition.
I totally disagree. From my point of view, the Bayfront Convention Center complex will strengthen the Scott development and vice versa. The facts presented to County Council confirm that.
KYLE FOUST, of Harborcreek Township, is a Democrat representing the 5th District on Erie County Council.


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Looks great in the bathroom, giving a spa look but I actually moved it to my patio outside. I have had it for about 3 years and still looks good. It's been rained on, had mud tracked over it too. I will be getting another eventually. It is worth the price but still more than I can afford right now. I love it and my company loves it too
Comments about Bamboo Bath Mat:
I had seen a similar bath mat for sale at a department store for 4x this price, with no visible difference I could see. Our bath mats would always get dingy no matter what we did, so we chucked them and now use this mat. It's great!
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Excllent value, used in company fitness rooms, well liked, long lasting
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I was super excited to buy this and try it out. In theory it would be amazing, but the slats are so wide it hurts to stand on. I thought maybe I was being sensitive so at first I went online to read these reviews and they were all positive. Therefore, I second guessed myself. Then today, I had my husband stand on it to see what he thought... (he had no idea I already hated it), He was like 'Ouch, it hurts!'
Comments about Bamboo Bath Mat:
One thing I dislike is that wet towel smell and skipping the step of hanging up a wet floor mat out of the shower may sound lazy, but it's nice how quickly it dries and there is no slippage as well, great product, buy it, you'll be happy.
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2009 Kingston Family Vineyards Sauvignon Blanc Cariblanco Casablanca Valley
Producer: Kingston Family Vineyards
Style: White Wine
Grape Type: Sauvignon Blanc
Origin: Chile
Region: Chile
90 Points | Stephen Tanzer's IWC - May/June 2011
($16) Bright straw. Shy aromas of lemon curd, pear and white flowers, with a touch of what I suspect smells like cannabis that gains strength with air. Light-bodied, juicy and complex, highlighted by fresh orchard fruit and candied citrus flavors and a silky, pliant texture. This wine has the heft to handle richer foods but there's a light touch as well. Finishes smooth and with very good persistence.


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Horrific accidents. Children beaten and mistreated. A doctor on horseback tripped by a wire. A barn lit ablaze.
In Michael Haneke's ice-cold The White Ribbon, a tranquil country village in pre-World War I Germany is shaken by a series of disturbing, puzzling events.
As he did in 2005's stomach-churningly creepy Caché, the Austrian writer-director leaves the ultimate cause, or source, of such ominous circumstances unclear. There are clues to point this way or that, but Haneke - more interested in the psychology of his characters than in something as piddling as plot - doesn't bother with conclusions.
Instead, in The White Ribbon, we are left to contemplate the seeds of fascism: The film, in its depiction of children exposed to emotional and physical violence, to humiliation and betrayal, to bigotry and hate, and to an unloving brand of Protestantism, represents the awful future of Germany - a future that leads to the Holocaust.


text: I spotted this UK site and it seems to have alot of cool stuff. I noticed the difference in covers and seeing the young face displayed on the book jacket really brings forth the the fact that this book is centered on a 16 year old girl. For those that have not read the book yet and need a little more incentive there is even a chapter sample to get your interest going. If that doesn't work, then maybe this interview with Suzanne Collins will do the trick.If you do, you will not be dissappointed.


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Star Tracks: Monday, May 16, 2016 42 years, 2,191 covers and 55,436 stories from PEOPLE magazine's history for you to enjoy
Latest News!
- Bryan Cranston, Susan Lucci and More React to All My Children Creator Agnes Nixon's Death
- Read the Cover Story: Brad & Angelina Split After 12 Years: It's Over
- Donald Trump on Alicia Machado's Miss Universe Reign: 'I Saved Her Job'
- José Fernández's Pregnant Girlfriend Maria Arias Makes First Public Appearance Since His Death at Memorial Service
- Utah Man Allegedly Held Teen in Shed For Six Weeks, Forcing Her to Perform Sex Acts for Food and Water
People Top 5
LAST UPDATE: Tuesday February 10, 2015 01:10PM EST
PEOPLE Top 5 are the most-viewed stories on the site over the past three days, updated every 60 minutes
- August 21, 2006
- Vol. 66
- No. 8
Joe Nichols Comes Clean
The Guy Behind 'Tequila Makes Her Clothes Fall Off' Admits Drinking and Drugs Made His Brain Shut Down—Until He Got Help
By the time he got to Steamboat Springs, however, Nichols had finally run aground. Bummed out by bad-weather flight delays, "I had drank a fifth and a half of Scotch and taken every pill I had in my pockets," he says. "I was screaming at everyone—incoherent babbling. I don't remember much."
"He had lost control, and it was clear he was in no shape to perform," says Lytle, who calmed his client down and arranged for him to see a therapist back home in Nashville two days later. Says Nichols: "I was scared and anxious and totally skeptical of the whole thing."
Today, Nichols, 29, readily credits his once-daily therapy sessions—which he now attends, he says, on an "as-needed basis"—for helping him kick his destructive habits. "I was still high the first time I went in," he says. "The therapist asked me not to drink or take drugs the rest of that day and the next. I felt I could do it one day at a time and not think about the next day till the next day." For the next eight months, he says, "I did not drink a single drop." It was during this time that he recorded what he calls his "blue skies and sunshine" album, III. (As for whether his hit single "Tequila Makes Her Clothes Fall Off" seems flip in light of his experience, he says, "It's just a fun song.") Nichols, who figures he had a beer a day starting in his early teens, now drinks occasionally, but it's not "to get hammered" as he once did. He has never considered himself an alcoholic or attended AA. ("AA's position," says a spokesperson, "is that it is up to the individual to determine if he or she is alcoholic.")
"Of course you remain alert to changes in behavior," says Lytle. "We have regular gut-check kinds of meetings. Since Joe stopped taking drugs, no longer drinks to excess and has been in therapy, I can see that on a day-to-day basis he deals with stress much better."
Through therapy Nichols gradually dealt with the roots of his substance abuse: depression, brought on by the guilt he felt over not properly grieving for his father, Mike, a long-distance trucker who died at 46 of pulmonary fibrosis in 2002, just as his son's career was taking off. Father and son had been estranged over a violent incident involving Joe's mother but patched things up before Mike fell ill. Right after the funeral, Nichols found himself booked for more than 200 tour dates. "The only way I could work and not think about him," he says, was through speed and booze. Now he's grateful for the times they did share, especially the Fourth of July right before Mike's death, during which "we just spent the day together talking."
And Nichols is working on building more family ties. He visits his mother and sister in Arkansas as often as he can, and he's consumed with being a dad to Ashelyn, his 8-year-old daughter by a former girlfriend—making sure she's eating her veggies, teaching her the fundamentals of baseball at minor-league Nashville Sounds games. When he's not on tour, Ashelyn stays with him Mondays through Thursdays at his house outside Nashville. "I still work hard," says the unattached Nichols, who will return to the recording studio after a yearlong gig opening for Toby Keith. "But I'm not using it as an excuse to run away from something anymore. What I do moves me toward something: towards time with my daughter, happiness, people I love and want to be with. In some way," he muses, "it pays for the mistakes my father made, and helps me put them to rest."
- Contributors:
- Kay West/Nashville.
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This symposium will explore the work, writings and legacy of this important and controversial modernist and their relationship to contemporary architecture, art and urbanism.
A utopian visionary, Le Corbusier was both innovative and influential in architecture, urbanism, art and theory. Across the world, his revolutionary designs were radical yet practical making him an instrumental figure in the development of Modernism. His buildings are credited with expressing a complex understanding of Modernity's impact. Many of his ideas on urban living became the blueprint for post-war reconstruction, while the failures of his imitators led to his being blamed for the problems of modern urbanism. Since his death in 1965, Le Corbusier's contributions have been hotly contested making him without a doubt one of the most admired and most maligned figures of the twentieth century. For Additional information: See our website at: HTTP://architecture.spsu.edu\annualdeanssymposium


text: 2008/7/17 <ihab.awad at gmail.com>: > > On Thu, Jul 17, 2008 at 11:03 AM, Jonathan S. Shapiro <shap at eros-os.com> > wrote: > >> Equally important, it constitutes an alleged type system that informally >> encapsulates many of the essential internal semantic relationships of >> the data set, and the transactional capabilities of a DBMS mean that you >> can do an all-or-nothing upgrade procedure on it. >> > > Interesting. The argument on the other side, of course, is that people miss > having Turing complete semantics to express the invariants and internal > relationships within that alleged type system. Hence database triggers > (horror!) and PL/SQL (septuple horror!). > What's wrong with database triggers? > What if one were to adopt the same sort of architecture, but consider the > "database" to be -- well -- a large vat with relatively simple semantics. > Upgrade it all in one big turn and we're done, and write its clients such > that they can be "rebooted" easily. Maybe orthogonal persistence is a sharp > knife to be used wisely. > > Ihab > > -- > Ihab A.B. Awad, Palo Alto, CA > > _______________________________________________ > cap-talk mailing list > cap-talk at mail.eros-os.org > http://www.eros-os.org/mailman/listinfo/cap-talk > > -------------- next part -------------- An HTML attachment was scrubbed... URL: http://www.eros-os.org/pipermail/cap-talk/attachments/20080717/5169d5c5/attachment.html


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Thursday, June 16th
67 Salem St.,
The North End, Boston
A fundraiser to benefit breast cancer research through Catwalk for a Cure and Susan G. Komen with local designers, a silent auction, appetizers, and cocktails.
Free admission!
Events in Boston: Catwalk for a Cure Fundraiser!
I am going to try to come!!
Great blog.Chanel may be known for its timeless designs, but with the introduction of the Chanel 2.55 Chanel brings us a line that is both seductive and a slight change of pace. Unmistakably different, Chanel classic strays from the quilted Chanel Evening Bags we have come to expect from the brand.
Good stuff.
great we'd love to join! :)
share the feeling
the cookies
visit <3
What a fabulous cause!
I would be there in a heartbeat if I was in Boston - it sounds like an incredible event! :)
would attend if I were there, sounds like a great event.
I'm glad everyone wants to do some good!


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Bad week for sponsored online poker site pros.
Two-time World Series of Poker bracelet winner and Latin America superstar Humberto "The Shark" Brenes was released as a sponsored pro by PokerStars this week.
MORE: Schemion, Smith flip-flop at the top of GPI World Rankings | Daniel Negreanu Player of the Month | WSOP November Nine Set
The Costa Rican's tournament career has spanned the better part of three decades, and includes $6.1 million in lifetime earnings along with ten cashes at this year's WSOP.
Brenes released a statement Monday in which he offered his opinion on whether more Team PokerStars Pros will be axed in coming weeks. "The amount of sponsored players could be reduced, but that's up to the new administration. I don't see it possible that the company could hire new faces for the team," said the 63-year-old.
PokerStars was recently acquired by Amaya Gaming for $4.9 billion.
Ultimate Poker, which has a licensed operation in the states of Nevada and New Jersey, also streamlined its sponsored pro roster earlier this week.
Former November Nine final table participants Jeremy Ausmus and Phil Collins, as well as William Reynolds, Lauren Kling and Brent Hanks, are no longer part of Team U.
That leaves the site, which is affiliated with the Ultimate Fighting Championship brand , with four sponsored players: Danielle Andersen, Dan O'Brien, Jason Sommerville and 2012 Big One for One Drop winner Antonio Esfandiari, who is the company's most prominently endorsed fixture.
Official poker site sponsorships have come under scrutiny in recent months following a controversial firing of Dale Philip from PokerStars in June.
Philip was filmed taking part in a bizarre celebration at a site-sponsored event in Spain as Spanish onlookers watched their team get smashed by Holland in a first-round World Cup match.


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RALEIGH, N.C. — Six-year-old Ashley Ramos-Hernandez died on Wednesday from injuries she sustained after being struck by an SUV as she disembarked her school bus.
Geraldine Baron Deitz, the driver of the vehicle that struck the girl, has been charged with misdemeanor death by motor vehicle and passing a stopped bus, The News & Observer reported.
Deitz reportedly told police that she saw the stopped school bus facing west on the street that she was driving on. She said that at first she stopped while waiting for the bus to turn south onto another street. When the bus did not turn, she told police, she continued to drive east and heard a thud.
Deitz continued on before realizing she had struck a child — then she stopped.
According to The News & Observer, Deitz said that the bus did not have all of its stop signals and markers activated. However, witnesses told police that the signals and markers were properly activated while Ramos-Hernandez and other children tried to cross the street.
Thomas Ernest Waters, a general contractor, was driving behind Deitz's Jeep prior to the accident. "The bus was at the top of the hill on North Hills Drive. It had its lights on. The stop light was out on the side. It had stopped and was letting kids off," Walters told the newspaper.
He went on to say that the Jeep slowed, but it did not stop, hitting and rolling over the girl.
Walters called 911 and stayed at the scene until emergency workers transported Ramos-Hernandez to the hospital. He found out after returning from work later that day that she passed away.
"She was just a young kid with her whole life ahead of her," Walters told The News & Observer. "It's beyond tragic."
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Berkeley, WV official reports show that a woman of 34 years age, Miledy Noa, was charged.
Berkeley, WV officials are reporting that Noa was busted Sunday.
Every effort has been made to ensure the integrity of these data, however, Local Blotter makes no claims of guarantee surrounding the accuracy of such alleged facts, as all suspects are to be considered innocent until proven guilty in a court of law.
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