Pregnancy in end-stage renal disease patients on dialysis: how to achieve a successful delivery

Ethics of abortion in transplantation

PURPOSE OF REVIEW

The controversial medical procedure of abortion is the subject of this article. It argues that for transplant patients, including recipients, abortion is ethical.

RECENT FINDINGS

In June 2022, the United States Supreme Court overturned the long-standing decision of Roe v. Wade. This decision has led to a socio-legal environment where obtaining an abortion is impossible for some patients. However, the moral position relating to patients who have undergone transplants or are on a waiting list has been largely overlooked. End-stage renal, liver, and heart disease presents a hazardous situation for pregnancy, posing risks to both the fetus and the pregnant person. The abortion procedure is medically safer and allows a patient to proceed with a transplant. Limiting access to abortion or preventing it altogether will have a significant negative impact on transplant patients. The ethical analysis of abortion can be likened to compelling a relative or loved one of a transplant recipient to donate an organ to their family member or loved one.

SUMMARY

This article emphasizes the importance of maintaining the legal availability of abortion for transplant patients. Allowing abortions in transplant patients upholds ethical parity, as seen in the analogous situation of live organ donation.

Lupus nephritis: management challenges during pregnancy

Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. Predominantly impacting women in their reproductive years, LN poses specific risks during pregnancy, including pre-eclampsia, growth restrictions, stillbirth, and preterm delivery, exacerbated by lupus activity, specific antibodies, and pre-existing conditions like hypertension. Effective management of LN during pregnancy is crucial and involves carefully balancing disease control with the safety of the fetus. This includes pre-conception counseling and a multidisciplinary approach among specialists to navigate the complexities LN patients face during pregnancy, such as distinguishing LN flare-ups from pregnancy-induced conditions. This review focuses on exploring the complex dynamics between pregnancy and LN, emphasizing the management difficulties and the heightened risks pregnant women with LN encounter.

Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanic/Latino individuals are less likely to receive optimal treatment for chronic kidney disease than non-Hispanic whites. This may be particularly detrimental for women of reproductive age as chronic kidney disease increases risk for infertility, menstrual irregularities, and pregnancy loss. While these maternal outcomes have been associated with advanced chronic kidney disease, their occurrence in early chronic kidney disease is unclear.

OBJECTIVES/DESIGN

Using baseline (2008-2011) and second study visit (2014-2017) data from the Hispanic Community Health Study/Study of Latinos, we retrospectively assessed the prevalence of chronic kidney disease as well as the association between chronic kidney disease and self-reported infertility, cessation of menses, hysterectomy, and nonviable pregnancy loss (experienced at less than 24 weeks gestation) in women of reproductive age (18-45 years).

METHODS

Multivariable survey logistic regression analyses determined the unadjusted and multivariable-adjusted prevalence odds ratios with 95% confidence intervals between chronic kidney disease and the separate outcomes.

RESULTS

Among 2589 Hispanic/Latino women included (mean age = 31.4 years), 4.6% were considered to have chronic kidney disease. In adjusted analyses, women with chronic kidney disease did not have a significantly increased odds of infertility (odds ratio = 1.02, 95% confidence interval = 0.42-2.49), cessation of menses (odds ratio = 1.25, 95% confidence interval = 0.52-3.04), or hysterectomy (odds ratio = 1.17, 95% confidence interval = 0.61-2.25) compared to those without chronic kidney disease. In those with chronic kidney disease, the adjusted odds of a nonviable pregnancy loss occurring after baseline visit were increased (odds ratio = 2.11, 95% confidence interval = 0.63-7.02) but not statistically significance.

CONCLUSION

The presence of early stage chronic kidney disease did not confer a significant risk of infertility, cessation of menses, or nonviable pregnancy loss.

Case report: 11 years on hemodialysis with a 4-year-old baby girl: A success story

Despite advances in clinical management and dialysis care, the outcome of unplanned pregnancy in women on maintenance hemodialysis (MHD) remains a difficult journey for the patient, fetus, and healthcare staff, particularly in low-resource countries. We report the successful outcome of a pregnancy in an anuric woman on twice-weekly maintenance hemodialysis for chronic glomerulonephritis since November 2012 in Cameroon. She was discovered pregnant at 18 weeks of gestation. The pregnancy was maintained until 36 weeks when a healthy 2,270 g female baby was delivered by elective cesarean section for tight nuchal cords and intrauterine growth retardation. The mother's post-partum period was uneventful. Except for hypoglycemia shortly after birth, the baby was fine. The patient is still on hemodialysis after 4 years, and the child is healthy and attending school.

Efficacy and safety of hemodialysis strategies for pregnant women with chronic kidney disease: Systematic review

Pregnancy in chronic kidney disease (CKD) women is relatively rare, and the less risky choice of hemodialysis is unknown. The objective of this systematic review was to identify, systematically evaluate and summarize the available evidence on the efficacy and safety of hemodialysis strategies for pregnant CKD women. Sensitive search strategies were applied to six databases without data or language restrictions. Comparative (randomized and non-randomized) studies were prioritized. Two reviewers independently selected, extracted, and critically evaluated data from studies. The risk of bias assessment was performed using the ROBINS-I tool, considering the study design (non-randomized comparative observational studies). The certainty of the evidence was assessed using the GRADE approach. From 7210 references identified, six retrospective cohort studies were included (576 women). The effects of intensive hemodialysis (over 20 h/week) are uncertain for maternal and neonatal mortality (Peto odds ratio [OR] 0.85; 95% confidence interval [95% CI] 0.26-2.80), miscarriage (Peto OR 0, 38; 95% CI 0.12-1.23), stillbirths (Peto OR 0, 56; 95% CI 0.13-2.31), preterm birth (Peto OR 0.87; 95% CI 0.33-2.28), low birth weight (Peto OR 0.71; 95% CI 0.20-2.50) and congenital anomalies rates. The certainty of the evidence was very low due to studies methodological limitations and effect estimates imprecision. The uncertainty about intensive versus conventional hemodialysis effects for pregnant women with CKD and the imprecision in the estimated effects precludes any recommendation. The strategy choice must consider treatment availability, costs, and maternal social aspects until future studies provide more reliable evidence. PROSPERO CRD42021259237.

Pregnancy in women on chronic dialysis in the last decade (2010-2020): a systematic review

Background

Pregnant women with end-stage renal disease on chronic dialysis are at a high risk of maternal and foetal complications. Over the years, the prognosis of their pregnancies has improved with advances in dialysis treatments and maternal and neonatal care. We conducted this systematic review to examine the recent data on maternal and foetal outcomes in pregnant women with end-stage renal failure on chronic dialysis over the last decade.

Methods

We made a systematic review of studies on pregnant women on chronic dialysis published between 1 January 2010 and 31 December 2020. We searched the following electronic databases: Medline via PubMed, Embase and the Cochrane Library, with search strategies for each database. We checked the titles and abstracts identified by the search equation, and two independent reviewers assessed the articles retrieved. For each study, the two reviewers separately recorded the data from each selected article on a standardized data extraction form. For each article, we recorded relevant general information on the study, patient demographic characteristics, dialysis schedule, pregnancy complications and outcomes, maternal complications, and foetal and neonatal outcomes.

Results

The literature search yielded 1668 potentially relevant abstracts. After reviewing the titles, abstracts and full text, we identified 14 studies according to the inclusion criteria. All studies were observational, nine of them were retrospective and eight were from a single-centre experience. The total number of women included in these studies was 2364 (range 8-2008) and the total number of pregnancies was 2754 (range 8-2352). The patients' ages ranged from 15 to 45 years. Obesity was observed in 808 (34.2%) women and ranged from 1 to 778. Haemodialysis was the predominant modality with 2551 (92.6%) pregnancies, and 203 (7.4%) on peritoneal dialysis. Overall, 68 out of 402 (16.9%) spontaneous miscarriages, 21 out of 402 (5.2%) therapeutic abortions and 26 (8.3%) stillbirths among 313 (stillbirths and live births) were recorded. The mean or median gestational age at delivery ranged from 25.2 to 36 weeks. The main maternal complications were preeclampsia 11.9%, hypertension 7.7% and anaemia 3.9%. Live births represented 287 (71.4%) out of 402 pregnancies, birth weight ranged from 590 to 3500 g and preterm birth was the main, most common complication in all studies, ranging from 50% to 100%. Intrauterine growth restriction was present in 5.9% and small-for-gestational-age was reported in 18.9% of neonates. There were 22 (7.6%) neonatal deaths among 287 live births and 48 (15.3%) perinatal deaths among 313 total births (stillbirths and live births).

Conclusions

Presumably, considering the increase in the number of publications and the total number of pregnancies reported therein, the frequency of pregnancy in patients with end-stage chronic kidney disease treated by chronic dialysis has increased. However, the practice of treating pregnant women on dialysis differs significantly among countries. These findings highlight the need to standardize the definition of outcomes and healthcare for pregnant women on dialysis.

V, Nono AET, Mekone IN, Mbala P, Kaze FF, Ashuntantang G. Spontaneous Twin Pregnancy: A Challenging and Exceptional Scenario in a Patient on Maintenance Hemodialysis in Sub-Saharan Africa

Chronic hemodialysis is associated with reduced fertility. Hence, pregnancy remains rare, challenging, and deleterious when unplanned, especially in low-resource countries. Contraception and births are very important in these settings. Though the main modes of contraception have been proposed in the chronic kidney disease (CKD) population, contraception still remains challenging in patients on maintenance hemodialysis. Most doctors, however, overlook contraception because of the low fertility, high rate of amenorrhea, and low libido. Furthermore, patients are less receptive to contraceptive counseling either because of a high desire to give birth or due to amenorrhea and low libido. Management of unplanned pregnancies is therefore very challenging and a multidisciplinary approach is the rule; however, it does not guarantee a good prognosis for both the mother and child. Very few cases of multiple pregnancies without induction of ovulation have been reported in patients with severe renal failure, especially those on maintenance dialysis. A 32-year-old multiparous woman with end-stage kidney failure (ESKF) and a residual diuresis of 700 mL per day who had been on inadequate maintenance hemodialysis for 36 months, presented with abdominal distension, which was confirmed on abdominal ultrasound to be a twin pregnancy at 22 weeks of gestation. Thereafter, we intensified hemodialysis (3 sessions/week), managed hypertension and anemia. The obstetrical course was uneventful until the 25th week of gestation when she developed grade 3 (WHO) hypertension and peripheral fluid overload. At the 29th week, she had a spontaneous vaginal preterm delivery of 2 babies weighing 1,350 g and 1,000 g, with an Apgar score of 8 and 7, respectively. Babies, however, died on day 1 and day 5 postpartum, respectively, from respiratory distress and early neonatal infection. The evolution of the mother was uneventful as she continued with her hemodialysis sessions. Twin pregnancies are a rare and very high-risk condition in end-stage renal disease and require multidisciplinary management.

Pregnancy in a woman undergoing peritoneal dialysis: Management and dialysis options

Pregnancy in patients with end-stage renal disease on maintenance dialysis is uncommon, with annual incidences reported at 0.3 - 2.7%. Peritoneal dialysis usage in pregnancy has been less reported than hemodialysis, although outcomes are similar. Nowadays, there are insufficient data to establish a generalizable dialysis strategy in pregnant women with end-stage renal disease. As such, decisions should be individualized, depending on clinical factors, residual renal function, and, whenever possible, choice of the patient. We report the case of a 22-year-old patient receiving peritoneal dialysis who delivered a full-term, normal weight, healthy baby with increased dialysis dose achieved by supplementary hemodialysis during pregnancy, thus enabling peritoneal dialysis to be continued until the third trimester and minimizing hemodialysis requirements.

Pregnancy and dialysis

The pregnancy rate of women on dialysis is still very low when compared to that of the remaining population. However, recent years have seen an increase in the success rates of these pregnancies. Among the main precautions that must be taken with pregnant women on dialysis are the maintenance of low levels of pre-dialysis urea, the adequacy of the tension profile, the control of anemia and care to avoid infections, nutritional deficits, changes in phosphorus-calcium metabolism and electrolytic fluctuations. It is also necessary to strictly monitor fetal growth and development. Pregnant women on dialysis have a higher probability of maternal and fetal complications; thus the importance of a multidisciplinary approach among nephrologists, obstetricians and pediatricians. The main objective of this study was to review the literature evidence available on pregnancy on dialysis, on the basic principles of the pathophysiology of pregnant women and their particularities in kidney disease. We will address available treatment options, benefits and risks, anticipating possible future challenges. At the end, we will present a clinical case to illustrate the topic.

Dialysis on Pregnancy: An Overview

Pregnancy rates in women on dialysis have increased in the last decades, thus making it a topic of growing interest. The rarity of this event is predominantly due to fertility problems and to the high rates of pregnancy failure including stillbirth, fetal, and neonatal deaths. We conducted a narrative review of existing literature in order to analyze the major issues about pregnancy on dialysis to give the reader a fully updated perspective about this topic which, even if not common, is becoming more and more frequent. Even if recently acquired knowledge has improved diagnosis and treatment of dialysis pregnancies focusing on several aspects, pregnancy on dialysis remains a great challenge for obstetricians and should be managed by a multidisciplinary expertise team. Dialysis in pregnancy may be necessary for women previously affected by end stage renal disease (ESRD) becoming pregnant, or in case of acute renal injury presenting for the first time during gestation or, again, in case of existent renal pathology worsening during pregnancy and requiring dialysis. Although some evidence suggests that more intensive dialysis regimens are correlated with better obstetric outcomes, the optimal therapeutic protocol still remains to be established.

Epilepsy management in pregnant HIV+ women in sub-Saharan Africa, clinical aspects to consider: a scoping review

BACKGROUND

Since the introduction of highly active antiretroviral therapy (HAART), acquired immune deficiency syndrome (AIDS) related mortality has markedly declined. As HAART is becoming increasingly available, the infection with human immunodeficiency virus (HIV+) in sub-Saharan Africa (SSA) is becoming a chronic condition. While pregnancy in HIV+ women in SSA has always been considered a challenging event for the mother and the fetus, for pregnant HIV+ women also diagnosed with epilepsy (WWE), there are additional risks as HIV increases the odds of developing seizures due to the vulnerability of the central nervous system to other infections, immune dysfunction, and overall metabolic disturbances. In light of a growing proportion of HIV+ WWE on HAART and an increasing number of pregnant women accessing mother-to-child transmission of HIV programs through provision of HAART in SSA, there is a need to develop contextualized and evidenced-based clinical strategies for the management of epilepsy in this population. In this study, we conduct a literature scoping review to identify issues that warrant consideration for clinical management.

RESULT

Twenty-three articles were retained after screening, which covered six overarching clinical aspects: status epilepticus (SE), Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), dyslipidemia, congenital malformation (CM), chronic kidney disease (CKD), and neurological development. No studies for our population of interest were identified, highlighting the need for a cautionary approach to be employed when extrapolating findings.

CONCLUSION

High risks of CM and drug interactions with first-line antiepileptic drugs (AEDs) warrant measures to increase the accessibility and choices of safer second-line AEDs. To ensure evidence-based management of epilepsy within this population, the potential high prevalence of SE, CKD, dyslipidemia, and SJS/TEN and the cumulative effect of drug-drug interactions should be considered. Further understanding of the intersections between pregnancy and drug-drug interactions in SSA is needed to ensure evidenced-based management of epilepsy in pregnant HIV+ WWE. To prevent SE, the barriers for AED treatment adherence in pregnant HIV+ women should be explored. Our review underscores the need to conduct cohort studies of HIV+ WWE in reproductive age over time and across pregnancies to capture the cumulative effect of HAART and AED to inform clinical management.

Contraception in Kidney Disease

Unplanned pregnancies account for a large number of encountered pregnancies. One of the reasons for this is the lack of counseling surrounding contraception and subsequently lack of contraception use. A conversation during a regular CKD office visit of simply asking a woman what her plans are regarding pregnancy can lead to further discussion on timing of pregnancy and contraception and eventually safer outcomes for both the mother and fetus. Individual preference, as well as comorbid conditions, should be taken into account when deciding on optimal contraceptive methods. One must remember that contraception counseling and initiation of contraception should not be wrapped up in a single office visit, and there must be continued follow-up to ensure that the woman is using the contraceptive method correctly to prevent any future unplanned pregnancy.

Intensified hemodialysis for complicated pregnancy in a primigravida with advanced maternal age: a case report with literature review focusing on appropriate hemodialysis management during pregnancy

Background

Pregnancy in dialysis patients is rare but challenging both for nephrologists and obstetricians. Although intensified hemodialysis is effective to achieve favorable clinical outcomes in this clinical setting, the evidence concerning reliable parameters for the optimal dialysis prescription is scarce. Herein, we report a case of a primigravida with advanced maternal age who underwent a normal spontaneous vaginal delivery at full term managed by intensified hemodialysis, and discuss reliable indicators of the appropriate dialysis prescription.

Case presentation

A 39-year-old primigravida with end-stage renal disease was referred to our department for hemodialysis management during pregnancy. She had a history of multiple gynecologic disorders, including cervical dysplasia, right tubal ectopic pregnancy and spontaneous abortion; consequently, she conceived through in vitro fertilization and embryo transfer. After pregnancy was confirmed, an intensified hemodialysis schedule with weekly duration of 36 hours was employed to prevent volume overload and the accumulation of hyperosmotic substances. Utilizing maternal blood pressure, plasma atrial natriuretic peptide levels and fetal development as indicators of volume status, we incremented her dry weight by 300–400 g per week in the first and second trimester and 100–200 g per week in the third trimester, respectively. Serum urea nitrogen levels were persistently maintained below 50 mg/dL. Throughout pregnancy, fetal growth and development were within normal limits. At 38 weeks and 3 days of gestation, she delivered a healthy child vaginally without complications. To date, the child’s development has been normal, both physically and mentally.

Conclusions

Pregnancy in dialysis patients with advanced age that leads to a normal childbirth is exceptionally rare. Our case is the hemodialysis patient with the most advanced age who achieves a normal spontaneous vaginal delivery at full term. Considering that cardiovascular system and endogenous metabolism dynamically alter during pregnancy, various clinical parameters should be closely monitored to modify dialysis settings accordingly. Of note, our case suggests that plasma atrial natriuretic peptide level is a useful parameter for the appropriate dry weight. Intensified hemodialysis is an effective and reliable measure that can achieve normal pregnancy in dialysis patients, even in a primigravida with advanced maternal age.

[Pregnancy in patients on chronic haemodialysis: about 25 cases which occurred in the south of Tunisia]

INTRODUCTION

the occurrence of pregnancy in patients on chronic haemodialysis is rare. However, given the evolution in dialysis technique, improvement in fertility is possible. The purpose of our study was to report our experience concerning the occurrence of pregnancy in patients on dialysis and to identify factors involved in its success.

METHODS

we conducted a retrospective study on 25 spontaneous pregnancies occurred in 19 patients treated with periodical hemodialysis in different hemodialysis centers in the south of Tunisia over a period of 34 years.

RESULTS

maternal age at the onset of pregnancy was, on average, 35.6 years [23-44 years] with an average seniority in hemodialysis of 4.22 years [1-17 years]. Seven patients (37%) had residual diuresis (>500 ml/24h). The prescribed weekly number of hours of dialysis was ≥16 hours per week in 7 cases and ≥20 hours in 4 cases. Success of pregnancy (new-born surviving at least 28 days) was estimated at 56%. The median gestational age was 34 weeks of amenorrhea [28-38 WA]. The average neonatal weight was equal to 1970g [1500g-2300g]. Analytical study showed a significant correlation between the increase in the hours of dialysis per week and the success of pregnancy (R=0.59; p=0.002).

CONCLUSION

it was noted that with adequate support and in particular, increasing the number of sessions of dialysis, materno-fetal complications can be minimized and the balance risk-benefit can turn the chance for a woman on dyalisis to become pregnant.

Delayed Initiation of Hemodialysis in Pregnant Women with Chronic Kidney Disease: Logistical Problems Impact Clinical Outcomes. An Experience from an Emerging Country

BACKGROUND

Chronic kidney disease (CKD) is associated with reduction of fertility and increased complications during pregnancy. The aim of this work is to analyze the clinical outcomes and risk factors in pregnant women who needed to start dialysis with different schedules in a public hospital in Mexico City, with particular attention on the interference of social and cultural elements as well as resource limitations.

MATERIAL AND METHODS

CKD women who needed dialysis in pregnancy over the period 2002⁻2014 and had with complete demographic and outcome data were included in this retrospective study. Clinical background, renal function during pregnancy, dialysis schedule, and clinical outcomes were reviewed.

RESULTS

Forty pregnancies in women with CKD who needed dialysis in pregnancy (39 singleton and one twin pregnancy) were studied: All patients were treated with hemodialysis. Thirty-nine patients had CKD stages 4 or 5 at referral; only one patient was of stage 3b. Dialysis was considered as indicated in the presence of fluid overload, unresponsive hypertension in the setting of advanced CKD, or when blood urea nitrogen values were increased to around 50 mg/dL. However, the initiation of dialysis was often delayed by days or weeks. The main reason for delaying the initiation of dialysis was patient (and family) refusal to start treatment. All patients were treated with thrice weekly dialysis, in 3⁻5 hour sessions, with a target urea of <100 mg/dL. The number of hours on dialysis did not impact pregnancy outcomes. Ten pregnancies ended in miscarriages (8 spontaneous), 29 in pre-term delivery, and 1 in term delivery. Fifteen women were diagnosed with preeclampsia, one with eclampsia, and one with HELLP (hemolysis, elevated liver enzymes, low platelets,) syndrome. Twenty-four of the neonates survived (77.4% of live births); six singletons and one twin died as a consequence of prematurity. Two neonates displayed malformations: cleft palate with ear anomalies and duodenal atresia.

CONCLUSIONS

CKD requiring hemodialysis in pregnancy is associated with a high frequency of complications; in the setting of delayed start and of thrice-weekly hemodialysis, dialysis schedules do not appear to influence outcomes.

Challenges of fertility preservation in non-oncological diseases

Clinicians should provide fertility counseling to all patients receiving gonadotoxic treatment. International scientific societies have mainly focused on oncological patients, and fewer efforts have been made to apply these recommendations to women diagnosed with benign disease (eg benign hematological diseases, autoimmune diseases, and gynecological or genetic disorders). However, these indications account for 8%-13% of the demand for fertility preservation. The risk of premature ovarian failure due to treatment, or to the disease itself, can be considered fairly high for many young women. Counseling and adequate management of these women require particular attention due to the severe health conditions that are associated with some of these diseases. In this review, we address specific issues related to providing adequate fertility counseling and management for women who have been diagnosed with the major non-oncological indications, based on the literature and on our clinical experience.

Successful pregnancy and delivery in uremic patients with maintenance hemodialysis: A case report

RATIONALE

It is reported that successful pregnancies in dialyzed uremic women are rare. Over the past years, despite advances in clinical management and technology in dialysis for pregnancy in patients receiving maintenance hemodialysis, uremia remains a high risk factor for adverse outcomes in mother and fetus.

PATIENT CONCERNS

In this article, we present a case of pregnancy in a 34-year-old uremic woman on dialysis. After the pregnancy was diagnosed and confirmed, intensive dialysis and multidisciplinary care according to the recommendations in the available literatures were provided.

DIAGNOSES

Single pregnancy of 31 GWs (gestational weeks), fetal growth restriction, polyhydramnios, and uremia.

OUTCOMES

At 31 weeks' gestation and 4 days, she was admitted to our hospital due to premature rupture of membranes and abdominal pain. Then a female baby weighed 1700 g was delivered successfully. After one year of follow-up, the mother feels well and the baby is healthy.

LESSONS

Intensive dialysis, detailed management and multidisciplinary approaches are necessary for optimal outcomes in uremic pregnant mother and fetus.

Twin pregnancy in a patient on chronic haemodialysis who already had three pregnancies

Pregnancy in women with end-stage renal disease is rare. Multiple pregnancies carry a high risk of complications even in healthy individuals. We report the case of a 36-year-old woman who had four pregnancies while she was on dialysis, including one twin pregnancy. The last pregnancy occurred while in the 14th year of hemodialysis. At 8 weeks of gestation (WG), ultrasonography diagnosed a dichorionic diamniotic twin pregnancy. The frequency of dialysis was increased from 3 to 6 times a week and each session lasted 4 h. At 22 WG, polyhydramnios was diagnosed. At 25 WG, the patient presented respiratory distress and was transferred to intensive care where continuous hemodialysis, non-invasive ventilation, antibiotic and tocolysis were initiated. Because of tocolysis failure, a cesarean section was performed and she delivered male twins. The two newborns weighed 790 and 870 g, respectively. To our knowledge, this is the first report of four pregnancies in hemodialysis including one twin pregnancy. The incidence of pregnancy and a better outcome in patients on hemodialysis has increased in recent years but a tight coordination between nephrologists and obstetricians is essential.

Risk Factors for Adverse Fetal Outcome in Hemodialysis Pregnant Women

Introduction

Pregnancy in women on dialysis is associated with a higher risk of adverse events, and the best care for this population remains to be established.

Methods

In this series, we aimed to identify factors associated with the risk of adverse fetal outcomes among 93 pregnancies in women on hemodialysis. Dialysis dose was initially assigned according to the presence of residual diuresis, body weight, and years on dialysis. Subsequent adjustments on dialysis dose were performed according to several parameters.

Results

The overall successful delivery rate was 89.2%, with a dialysis regimen of 2.6 ± 0.7 h/d, 15.4 ± 4.0 h/wk, and mean weekly standard urea Kt/V of 3.3 ± 0.6. In the logistic models, preeclampsia, lupus, primigravida, and average midweek blood urea nitrogen (BUN) level were positively related to the risk of a composite outcome of perinatal death or extreme prematurity, whereas polyhydramnios was inversely related to it. In multivariable linear regression, preeclampsia, polyhydramnios, primigravida, average midweek BUN, and residual diuresis remained significantly and independently related to fetal weight, which is a surrogate marker of fetal outcome. An average midweek BUN of 35 mg/dl was the best value for discriminating the composite outcome, and BUN ≥35 mg/dl was associated with a significant difference in a Kaplan-Meier curve (P = 0.01).

Conclusion

Our results showed that a good fetal outcome could be reached and that preeclampsia, lupus, primigravida, residual diuresis, polyhydramnios, and hemodialysis dose were important variables associated with this outcome. In addition, we suggested that a midweek BUN <35 mg/dl might be used as a target for adjusting dialysis dose until hard data were generated.

Effect of ultrafiltration on placental-fetal blood flow in pregnancy of woman undergoing chronic hemodialysis

INTRODUCTION

Patient who was undergoing hemodialysis (HD) thrice weekly usually gain 1 to 4 kg of weight in interdialytic period, mainly due to fluid accumulation by ingestion of water. Ultrafiltration (UF) during HD will be need to remove fluid excess to avoid severe medical complications secondary to fluid overload. However, in pregnant woman UF can increase the episodes of intradialytic hypotension which may lead to placental ischemic injury and predispose to fetal distress. There is little information about safe fluid amount withdrawn by UF during pregnancy.

METHODS

We prospectively study by obstetric Doppler ultrasonography the fluxometric parameters: pulsatility index (PI) and resistance index (RI) of fetal middle cerebral, uterine, and umbilical artery obtained at the beginning and the end of HD session, the acute and chronic effect of UF on placenta and fetus blood flow, as well as the fetal outcome in 1 pregnant woman on chronic HD.

FINDINGS

We did not observe any acute harmful effect on fetal middle cerebral, placental and umbilical artery blood flow when UF rate of 2.1 ± 0.04 L (6 < 8 mL/h/kg) during HD session, no significant statistical difference was observed when compared PI and RI before and after UF and also when we compared these data with reference value on normal pregnancy to the same gestational age.

DISCUSSION

UF rate of 6 < 8 mL/h/kg during HD did not bring any acute harmful effect on fetal middle cerebral, placental, and umbilical blood flow and the UF rate of 1.4 6 0.4 L (< 6 mL/h/kg) / HD session that was done in all others HD during pregnancy was safe, without any chronic fetal deleterious effect. Obstetric Doppler ultrasonography is a simple and noninvasive method to fetal follow-up and can aid to determine safe UF rate in pregnant women during gestation.

Pregnancy outcomes in women on hemodialysis: a national survey

Background. Pregnancy occurs among 1–7% of women on chronic dialysis. Experience regarding pregnancy and dialysis originates from anecdotal reports, case series and surveys. This survey updates the US nephrologists’ experience with pregnancy on hemodialysis (HD) over the past 5 years. We evaluated maternal and fetal outcomes, certain practice patterns such as dialysis regimens utilized and nephrologist knowledge and comfort level when caring for a pregnant patient on HD.

Methods. An anonymous Internet-based 23-question survey was e-mailed to end-stage renal disease Networks of America program directors for forwarding to practicing nephrologists.

Results. A total of 196 nephrologists responded to the survey, reporting >187 pregnancies. Of the respondents, 45% had cared for pregnant females on HD and 78% of pregnancies resulted in live births. In 44% of the pregnancies a diagnosis of preeclampsia was made. There were no maternal deaths. Nephrologists most commonly prescribe 4–4.5 h of HD 6 days/week for pregnant women on dialysis. Women dialyzed cumulatively for >20 h/week were 2.2 times more likely to develop preeclampsia than those who received ≤20 h of HD per week.

Conclusion. Providing intensive HD is a common treatment approach when dialyzing pregnant women. Maternal and fetal outcomes can be improved. There is a trend toward better live birthrates with more intense HD. Whether more cumulative hours of dialysis per week increases the risk of preeclampsia needs to be further investigated.

Maternal Mineral and Bone Metabolism During Pregnancy, Lactation, and Post-Weaning Recovery

During pregnancy and lactation, female physiology adapts to meet the added nutritional demands of fetuses and neonates. An average full-term fetus contains ∼30 g calcium, 20 g phosphorus, and 0.8 g magnesium. About 80% of mineral is accreted during the third trimester; calcium transfers at 300-350 mg/day during the final 6 wk. The neonate requires 200 mg calcium daily from milk during the first 6 mo, and 120 mg calcium from milk during the second 6 mo (additional calcium comes from solid foods). Calcium transfers can be more than double and triple these values, respectively, in women who nurse twins and triplets. About 25% of dietary calcium is normally absorbed in healthy adults. Average maternal calcium intakes in American and Canadian women are insufficient to meet the fetal and neonatal calcium requirements if normal efficiency of intestinal calcium absorption is relied upon. However, several adaptations are invoked to meet the fetal and neonatal demands for mineral without requiring increased intakes by the mother. During pregnancy the efficiency of intestinal calcium absorption doubles, whereas during lactation the maternal skeleton is resorbed to provide calcium for milk. This review addresses our current knowledge regarding maternal adaptations in mineral and skeletal homeostasis that occur during pregnancy, lactation, and post-weaning recovery. Also considered are the impacts that these adaptations have on biochemical and hormonal parameters of mineral homeostasis, the consequences for long-term skeletal health, and the presentation and management of disorders of mineral and bone metabolism.

When it rains, it pours: Peripartum cardiomyopathy with features of left-ventricular noncompaction in a hemodialysis patient

Pregnancy and associated pre-eclampsia carry a high maternal risk in hemodialysis patients, yet no guidelines on how to monitor these patients' cardiovascular function exist. A 34-year-old hemodialysis patient presented with peripartum cardiomyopathy after a late second trimester miscarriage. On cardiac magnetic resonance imaging, diagnostic features of left ventricular noncompaction were apparent. Yet, histological and gene panel analyses remained negative. Upon stringent dry weight control and pharmacological heart failure therapy, the pathological changes showed complete regression. As pregnant hemodialysis patients have an excessively increased risk for pre-eclampsia-related cardiac disease, thorough screening appears valuable in these patients.

The successful clinical outcomes of pregnant women with advanced chronic kidney disease

Background

Successful pregnancy outcomes in patients with advanced chronic kidney disease (CKD) are increasingly common in Western countries. However, in Korea, the available literature addressing this clinical issue is scarce.

Methods

We reviewed 5 successful parturitions [1 patient with Stage 5 CKD and 4 with maintenance hemodialysis (HD)] at Seoul St. Mary's Hospital over 3 years and investigated changes in dialysis prescription, anemia management, and the incidence of maternal and neonatal complications.

Results

There were no maternal or neonatal deaths in this cohort. The mean age at the time of conception and delivery was 35.8 ± 3.7 and 36.2 ± 3.5 years, respectively. Dialysis patients received more frequent and intensified HD during pregnancy, 20.0 ± 5.7 h/wk of HD over 5 visits with the ultrafiltration dose maintained between 1 and 2 kg per session. All patients received erythropoietin-stimulating agents and iron replacement therapy during pregnancy. The mean hematocrit was 33.1 ± 1.9% before pregnancy and was well maintained during gestation (33.9 ± 3.8% at the first trimester, 29.2 ± 4.2% at the second trimester, and 33.6 ± 8.7% at delivery). The mean gestation period was 32.7 ± 4.7 weeks, with 60% of patients experiencing premature delivery. The primary maternal complication was pre-eclampsia; 3 women developed pre-eclampsia and underwent emergency cesarean sections. Most neonatal complications were related to preterm birth.

Conclusion

Dialysis-related care and general clinical management improved the clinical outcome of pregnancy for patients with advanced CKD.

Got Milk? Breastfeeding and Milk Analysis of a Mother on Chronic Hemodialysis

PURPOSE

Women on dialysis rarely become pregnant. However, the overall rate of successful pregnancies is increasing in this patient population and breastfeeding becomes an option for mothers on dialysis. In this study we performed a systematic breast milk composition analysis of a mother on chronic hemodialysis (HD).

METHODS

Specimens of breast milk and blood were collected in regular intervals before and after HD from a 39-year old woman starting on day 10 postpartum. Samples were analyzed for electrolytes, retention solutes, nutrients and other laboratory measurements. Breast milk samples from low-risk mothers matched for postpartum age were used as controls.

RESULTS

Significantly higher levels of creatinine and urea were found in pre-HD breast milk when compared to post-HD. A similar post-dialytic decrease was only found for uric acid but not for any other investigated parameter. Conversely, sodium and chloride were significantly increased in post-HD samples. Compared to controls creatinine and urea were significantly higher in pre-HD samples while the difference remained only significant for post-HD creatinine. Phosphate was significantly lower in pre- and post-HD breast milk when compared to controls, whereas calcium showed no significant differences. In terms of nutrient components glucose levels showed a strong trend for a decrease, whereas protein, triglycerides and cholesterol did not differ. Similarly, no significant differences were found in iron, potassium and magnesium content.

CONCLUSION

To the best of our knowledge this is the first report on a breastfeeding mother on chronic dialysis. Although we found differences in creatinine, urea, sodium, chloride and phosphate, our general analysis showed high similarity of our patient's breast milk to samples from low-risk control mothers. Significant variations in breast milk composition between pre- and post-HD samples suggest that breastfeeding might be preferably performed after dialysis treatment. In summary, our findings indicate that breastfeeding can be considered a viable option for newborns of mothers on dialysis.