Pregnancy in Peritoneal Dialysis: A Case Report and Review of Adequacy and Outcomes

Pregnancy in Patients Receiving Home Dialysis

Pregnancy is an important goal for many women with CKD or kidney failure, but important barriers exist, particularly as CKD stage progresses. Women with advanced CKD often have a limited fertility window and may miss their opportunity for a pregnancy if advised to defer until after kidney transplantation. Pregnancy rates in women with advanced kidney failure or receiving dialysis remain low, and despite the improved outcomes in recent years, these pregnancies remain high risk for both mother and baby with high rates of preterm birth due to both maternal and fetal complications. However, with increased experience and advances in models of care, this paradigm may be changing. Intensive hemodialysis regimens have been shown to improve both fertility and live birth rates. Increasing dialysis intensity and individualizing dialysis prescription to residual renal function, to achieve highly efficient clearances, has resulted in improved live birth rates, longer gestations, and higher birth weights. Intensive hemodialysis regimens, particularly nocturnal and home-based dialysis, are therefore a potential option for women with kidney failure desiring pregnancy. Global initiatives for the promotion and uptake of home-based dialysis are gaining momentum and may have advantages in this unique patient population. In this article, we review the epidemiology and outcomes of pregnancy in hemodialysis and peritoneal dialysis recipients. We discuss the role home-based therapies may play in helping women achieve more successful pregnancies and outline the principles and practicalities of management of dialysis in pregnancy with a focus on delivery of home modalities. The experience and perspectives of a patient are also shared.

Successful multigravid pregnancy in a 42-year-old patient on continuous ambulatory peritoneal dialysis and a review of the literature

Background

For peritoneal dialysis patients, the likelihood of conception is low and the probability of getting through the pregnancy successfully is even lower. Almost 60 years after the first reported case of a successful pregnancy in a dialysis patient, many issues concerning pregnancy in dialysis patients remain unresolved. Our patient’s pregnancy is considered high risk as she has end stage renal failure and falls in the category of advance maternal age for pregnancy. We describe here the course of her uneventful pregnancy which we hope will contribute to the overall knowledge and management of pregnancy in elderly patients receiving peritoneal dialysis.

Case presentation

We report a successful elderly multigravid pregnancy, in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD). Her pregnancy was detected early and she was closely managed by the nephrologist and obstetrician. She tolerated the same PD prescription throughout 36 weeks of pregnancy with daily ultrafiltration of 500-1500mls. Her blood pressure remained well controlled without the need of any antihypertensive medication. Her total Kt/V ranged from 1.93 to 2.73. Her blood parameters remained stable and she was electively admitted at 36 weeks for a trans-peritoneal lower segment caesarian section and bilateral tubal ligation.

Conclusions

At the age of 42, our case is the oldest reported successful pregnancy in a patient on peritoneal dialysis. With careful counselling and meticulous follow up, we have shown that woman in the early stage of end stage renal failure can successfully deliver a full term baby without any complications. Therefore, these women should not be discourage from conceiving even if they are in advanced maternal age for pregnancy.

Pregnancy in advanced chronic kidney disease and end-stage renal disease

PURPOSE OF REVIEW

This article reviews the available literature about the incidence, outcomes, and the management of pregnancy in women with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) who require renal replacement therapy.

RECENT FINDINGS

Pregnancy in women with advanced CKD and ESRD can result in serious adverse maternal and fetal outcomes, but improved outcomes have been noted in recent years, likely secondary to intensified dialysis regimens. More intensive dialysis allows for the gentle removal of water, solutes, and uremic toxins, which theoretically results in near-normal maternal renal physiology, an improvement in placental blood flow, and therefore a better environment for fetal growth and development. As management remains complex, a close joint collaboration between the high-risk obstetrical team and nephrology is essential.

SUMMARY

Pregnancy on dialysis is becoming a viable option for women with advanced CKD and ESRD who do not have immediate access to transplantation.

Two successive pregnancies in a patient during 14 years of hemodialysis: a case report

Background

The incidence of pregnancy in women with end-stage renal disease seems to be increasing. Improvements in dialysis, obstetrical care, and antenatal fetal monitoring over the past two decades appear to have increased fertility rates and successful pregnancies in dialysis-dependent women. A pregnancy with a successful outcome despite the long dialysis period, as in the patient described here, is very rarely reported in the literature.

Case presentation

I report a case of a 34-year-old white Kurdish woman who had had two uncomplicated pregnancies while on hemodialysis, with delivery of healthy babies. The first pregnancy occurred in the eighth year of her hemodialysis and ended in the 32nd week of gestation with healthy vaginal delivery of a 1900-g baby. The second pregnancy occurred in the 14th year of her hemodialysis and ended in the 30th week of gestation, with vaginal delivery of a 1400-g baby. The second baby, who had respiratory problems, was discharged after 45 days of intensive care.

Conclusions

Although pregnancy during the hemodialysis is risky, the outcomes of the pregnancies could be improved by an intensive hemodialysis regimen, appropriate anemia management, strict blood pressure follow-up, and correct evaluation of the dry weight.

Best practices on pregnancy on dialysis: the Italian Study Group on Kidney and Pregnancy

BACKGROUND

Pregnancy during dialysis is increasingly being reported and represents a debated point in Nephrology. The small number of cases available in the literature makes evidence-based counselling difficult, also given the cultural sensitivity of this issue. Hence, the need for position statements to highlight the state of the art and propose the unresolved issues for general discussion.

METHODS

A systematic analysis of the literature (MESH, Emtree and free terms on pregnancy and dialysis) was conducted and expert opinions examined (Study Group on Kidney and Pregnancy; experts involved in the management of pregnancy in dialysis in Italy 2000-2013). Questions regarded: timing of dialysis start in pregnancy; mode of treatment, i.e. peritoneal dialysis (PD) versus haemodialysis (HD); treatment schedules (for both modes); obstetric surveillance; main support therapies (anaemia, calcium-phosphate parathormone; acidosis); counselling tips.

MAIN RESULTS

Timing of dialysis start is not clear, considering also the different support therapies; successful pregnancy is possible in both PD and HD; high efficiency and strict integration with residual kidney function are pivotal in both treatments, the blood urea nitrogen test being perhaps a useful marker in this context. To date, long-hour HD has provided the best results. Strict, personalized obstetric surveillance is warranted; therapies should be aimed at avoiding vitamin B12, folate and iron deficits, and at correcting anaemia; vitamin D and calcium administration is safe and recommended. Women on dialysis should be advised that pregnancy is possible, albeit rare, with both types of dialysis treatment, and that a success rate of over 75% may be achieved. High dialysis efficiency and frequent controls are needed to optimize outcomes.

Peritoneal dialysis prescription during the third trimester of pregnancy

Management of the pregnant patient on peritoneal dialysis (PD) is potentially challenging because uterine enlargement may negatively affect catheter function and prescribed dwell volumes. Additional reports of the management of these patients are needed. Here, we describe a near-full-term delivery in a 27-year-old woman who had been on dialysis for 7 years. Peritoneal dialysis was continued during the entire pregnancy. In the third trimester, a higher delivered automated PD volume allowed for adequate clearance and control of volume status. A decision to hospitalize the patient to limit activity and facilitate the delivery of increased dialysate is believed to have contributed to the successful outcome for mother and infant. Our report discusses the management of this patient and reviews published dialysis prescriptions used during the third trimester of pregnancy in patients treated with PD.

Pregnancy in end stage renal disease

The ovulatory menstrual cycle is known to be affected on multiple levels in women with advanced renal disease. Menstrual irregularities, sexual dysfunction, and infertility worsen in parallel with the renal disease. Pregnancy in women with ESRD on dialysis is therefore uncommon. Furthermore, when pregnancy does occur, it can prove hazardous to both mother and baby owing to a multitude of potential complications including accelerated hypertension and preeclampsia, poor fetal growth, anemia, and polyhydramnios. Data are emerging, however, to suggest that pregnancy while on intensified renal replacement regimens may result in better pregnancy outcomes, and emerging trends include the decreased rate of therapeutic abortions probably reflecting a change in counseling practices over time. Nevertheless, a pregnant woman on intensive dialysis requires meticulous follow-up by a dedicated team including nephrology, obstetrics, and a full multidisciplinary staff. In this article, we will address fertility issues in young women with ESRD, review pregnancy outcomes in women on both hemodialysis and peritoneal dialysis, and provide suggestions for the management of the pregnant women on intensive hemodialysis.

Management of renal disease in pregnancy

Although renal disease in pregnancy is uncommon, it poses considerable risk to maternal and fetal health. This article discusses renal physiology and assessment of renal function in pregnancy and the effect of pregnancy on renal disease in patients with diabetes, lupus, chronic glomerulonephritis, polycystic kidney disease, and chronic pyelonephritis. Renal diseases occasionally present for the first time in pregnancy, and diagnoses of glomerulonephritis, acute tubular necrosis, hemolytic uremic syndrome, and acute fatty liver of pregnancy are described. Finally, therapy of end-stage renal disease in pregnancy, dialysis, and renal transplantation are reviewed.

Obstetric outcomes in women with end-stage renal disease on chronic dialysis: a review

Pregnancies in women on chronic dialysis for end-stage renal disease are high risk, but outcomes appear to have improved with increasing experience and advances in dialysis care. This paper reviews the existing data on outcomes in such pregnancies to enable evidence-based preconception counselling and anticipation of antenatal complications.

Intensifying renal replacement therapy during pregnancy: the role for nocturnal home hemodialysis

Fertility among women receiving conventional hemodialysis or peritoneal dialysis is very low. For those able to conceive it appears that infant survival is poor, and prematurity and its related complications are still commonplace. Nocturnal hemodialysis (NHD) is a form of intensive, self-administered hemodialysis whereby patients receive 3-4 times the duration of conventional hemodialysis resulting in superior removal of uremic toxins compared to traditional dialysis modalities. NHD has been associated with increased fertility, infants with higher birth weights born at more advanced gestational ages, and fewer maternal and fetal complications. These encouraging results suggest a greater role for much more intensive dialysis in pregnancy.

Intradialytic hyperalimentation as adjuvant support in pregnant hemodialysis patients: case report and review of the literature

Pregnancy in chronic dialysis patients is unusual and associated with many complications. Infants are often born both prematurely and small for gestational age. We report a case of a 36-year-old diabetic hemodialysis patient G4P3 who had prolonged hyperemesis gravidarum, for whom intradialytic parenteral nutrition (IDPN) was started at week 14 and continued throughout her pregnancy. She delivered a 3.5-kg baby girl at the 36th week of gestation by cesarean section. We discuss the use of IDPN as adjunct therapy for pregnant dialysis patients.

Pregnancy in patients on chronic dialysis: a single center experience and combined analysis of reported results

OBJECTIVE(S)

Pregnancy is rare in patients on chronic dialysis, with only a 30-50% rate of successful delivery reported in a previous review article. The pregnancy outcome has improved in recent decades, but data on pregnancy outcome are limited due to the small sample size of previous case series. This study investigated the pregnancy outcome in patients on chronic dialysis over the past 15 years in a single center, and also performed a combined analysis of results of individual cases from previously reported series to obtain overall estimates of rates of successful delivery.

STUDY DESIGN

Medical records for a total of 13 pregnancies in 13 women undergoing chronic dialysis (10 on hemodialysis and 3 on peritoneal dialysis) during the period from 1990 to 2006 in our hospital were retrospectively reviewed. Data on the changes in dialysis regimen, medical complications, obstetric conditions, and perinatal problems were collected. An electronic search of PubMed identified 10 case series studies and 12 case reports published after 1990 with adequate individual information available. Pooled data from a total of 131 cases, including our patients (117 hemodialysis and 14 peritoneal dialysis), were analyzed using the chi(2)-test and the t-test to compare the rate of successful delivery and birth weight in the hemodialysis group and the peritoneal dialysis group, and in pregnancies with conception prior to and those with conception after starting dialysis.

RESULTS

Among the 10 pregnant women who decided to continue their pregnancies in our hospital, 5 delivered live newborns and 5 pregnancies ended with intra-uterine fetal demise or neonatal death. The overall rate of successful delivery was 70.9% (83 out of 117) in patients on hemodialysis and 64.2% (9/14) in patients on peritoneal dialysis. The birth weight for these groups was 1483+/-116 and 1623+/-320 g, respectively. The difference in the rates of successful delivery in these two groups was not significant (p=0.61). However, the birth weight was significantly greater in patients who conceived after than those who conceived prior to starting hemodialysis (1529+/-132 g versus 1245+/-200 g; p=0.04).

CONCLUSIONS

This study found that the outcome of pregnancy on chronic dialysis has improved in recent decades, but our study showed no significant difference in the rate of successful delivery between patients on hemodialysis and those on peritoneal dialysis.