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Baouche H, Couchoud C, Boulanger H, Ahriz-Saksi S, Mansouri I, Hamani A, Taupin P, Ferreira X, Panaye M, Stirnemann J, Moranne O, Jais JP. Pregnancy Among Women Receiving Chronic Dialysis in France (2006-2020). Kidney Int Rep 2024; 9:2432-2442. [PMID: 39156151 PMCID: PMC11328538 DOI: 10.1016/j.ekir.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 08/20/2024] Open
Abstract
Introduction In women receiving chronic dialysis, fertility is impaired. The objectives of this study were to estimate the incidence rate of pregnancies among women of childbearing age (15-50 years) receiving chronic dialysis from 2006 to 2020 in France, to describe the pregnancy outcomes and renal management during pregnancy. Methods This national observational, retrospective study was based on data from the French REIN registry matched with the National Health Data System. Results Over the period 2006 to 2020 in France, 348 pregnancies were identified in 240 women receiving chronic dialysis. The overall incidence of pregnancy was 11.1, 95% confidence interval (CI) (9.9-12.3) cases per 1000 person-years. Hemodialysis was the predominant modality during pregnancy. Main maternal complications were preeclampsia (n = 19) and gestational diabetes (n = 11). The most obstetric complications were premature rupture of membranes (n = 14) and polyhydramnios (n = 5). These pregnancies resulted in 174 (50%) abortions (<22 weeks), including 104 elective abortions (29.9%), 44 miscarriages (12.6%), 17 therapeutic abortions (4.9%), 5 ectopic pregnancies (1.4%), and 4 hydatidiform moles (1.2%). The remaining 174 (50%) pregnancies with deliveries (≥22 weeks) resulted in 166 live births (70 full-term [42.2%], 96 preterm births [57.8%]), and 8 stillbirths. Median gestational age was 36 weeks (32-38) for 174 deliveries. Conclusion There have been improvements in maternal and fetal outcomes regarding pregnancy on chronic dialysis. However, our study shows a significant proportion of elective abortions. Better fertility management of women receiving chronic dialysis is advised by contraception or by pregnancy planning and early multidisciplinary follow-up.
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Affiliation(s)
- Hayet Baouche
- Biostatistics Department, APHP-Necker-Enfants Malades Hospital, REIN Registry, Paris, France
| | - Cécile Couchoud
- French REIN registry, Agence de la Biomédecine, La Plaine Saint-Denis, Paris, France
| | - Henri Boulanger
- Nephrology and Dialysis Department, Estrée Clinic, Stains, Paris, France
| | - Salima Ahriz-Saksi
- Nephrology and Dialysis Department, Estrée Clinic, Stains, Paris, France
| | - Imene Mansouri
- French REIN registry, Agence de la Biomédecine, La Plaine Saint-Denis, Paris, France
| | - Abdelaziz Hamani
- Dialysis Department, Jules Valles Hospital, Athis Mons, Essonne, France
| | - Pierre Taupin
- Medical information Department-PMSI, APHP-Necker-Enfants Malades Hospital, Paris, France
| | - Xavier Ferreira
- Medical information Department-PMSI, APHP-Necker-Enfants Malades Hospital, Paris, France
| | - Marine Panaye
- Nephrology Department, Edouard-Herriot Hospital, Pavilion P5, Lyon, France
| | - Julien Stirnemann
- Obstetrics and Maternal-Fetal Medicine Department, APHP-Necker-Enfants Malades Hospital, Paris, France
- Research Team EA 7328, Paris Cité University, Paris, France
| | - Olivier Moranne
- Nephrology, Dialysis-Apheresis Unit, Caremeau University Hospital, Nîmes, France
- UMR Inserm-UM, Desbrest Institute of Epidemiology and Public Health, Montpellier, France
| | - Jean-Philippe Jais
- Biostatistics Department, APHP-Necker-Enfants Malades Hospital, REIN Registry, Paris, France
- Research Team EA 7328, Paris Cité University, Paris, France
| | - REIN registry
- Biostatistics Department, APHP-Necker-Enfants Malades Hospital, REIN Registry, Paris, France
- French REIN registry, Agence de la Biomédecine, La Plaine Saint-Denis, Paris, France
- Nephrology and Dialysis Department, Estrée Clinic, Stains, Paris, France
- Dialysis Department, Jules Valles Hospital, Athis Mons, Essonne, France
- Medical information Department-PMSI, APHP-Necker-Enfants Malades Hospital, Paris, France
- Nephrology Department, Edouard-Herriot Hospital, Pavilion P5, Lyon, France
- Obstetrics and Maternal-Fetal Medicine Department, APHP-Necker-Enfants Malades Hospital, Paris, France
- Research Team EA 7328, Paris Cité University, Paris, France
- Nephrology, Dialysis-Apheresis Unit, Caremeau University Hospital, Nîmes, France
- UMR Inserm-UM, Desbrest Institute of Epidemiology and Public Health, Montpellier, France
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2
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Shah S, Weinhandl E, Leonard AC, Rachwal B, Verma P, Perl J, Christianson AL. Pregnancies in Women With Kidney Failure on Home Dialysis in the United States. Kidney Int Rep 2024; 9:907-918. [PMID: 38765588 PMCID: PMC11101807 DOI: 10.1016/j.ekir.2024.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Revised: 01/16/2024] [Accepted: 01/22/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Women with kidney failure have impaired fertility and are at a higher risk of maternal and fetal morbidity and mortality. Little is known about pregnancies in women receiving maintenance home dialysis in the United States. Methods Using data from the United States Renal Data System (USRDS), a cohort of 26,387 women aged 15 to 49 years with kidney failure receiving maintenance home dialysis from 2005 to 2018 was examined. We calculated pregnancy rates and identified factors, including the modality associated with pregnancy receiving home dialysis. Results Overall, 437 pregnancies were identified in 26,837 women on home dialysis. The unadjusted pregnancy rate was 8.6 per 1000 person-years (PTPY). The unadjusted pregnancy rate was higher on home hemodialysis (16.0 vs. 7.5 PTPY) than on peritoneal dialysis. Women receiving home hemodialysis had a higher adjusted likelihood of pregnancy than women receiving peritoneal dialysis (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.79-3.05). Compared with women aged 20 to 24 years, the likelihood of pregnancy was lower in women aged 30 to 34 years (HR, 0.64; 95% CI, 0.43-0.96), 35 to 39 years (HR, 0.53; 95% CI, 0.35-0.79), 40 to 44 years (HR, 0.32; 95% CI, 0.21-0.49), and 45 to 49 years (HR, 0.21; 95% CI, 0.13-0.33). Whereas Black women had a higher likelihood of pregnancy (HR, 1.40; 95% CI, 1.07-1.83), there was no difference in likelihood of pregnancy in Asian, Hispanic, and Native Americans as compared to Whites. Body mass index, cause of kidney failure, socioeconomic status, rurality, predialysis nephrology care, or dialysis vintage were not significantly associated with pregnancy on home dialysis. Conclusion The pregnancy rate in women with kidney failure undergoing home dialysis is higher with home hemodialysis than with peritoneal dialysis. Younger age and Black race or ethnicity are associated with a higher likelihood of pregnancy among women receiving home dialysis. This information can guide clinicians in preconception counselling and making informed treatment decisions for pregnant women on home dialysis.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, Ohio, USA
| | - Eric Weinhandl
- Satellite Healthcare, San Jose, California, USA
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, Minnesota, USA
| | - Anthony C. Leonard
- Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA
| | - Brenna Rachwal
- Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA
| | - Prasoon Verma
- Division of Neonatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey Perl
- St. Michael's Hospital, University of Toronto, Ontario, Canada
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3
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Younis D, Shemies RS. The unanswered question. When to undertake a maternity journey? J Nephrol 2024; 37:835-836. [PMID: 38285317 PMCID: PMC11150280 DOI: 10.1007/s40620-023-01865-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 12/12/2023] [Indexed: 01/30/2024]
Affiliation(s)
- Dalia Younis
- Mansoura Nephrology and Dialysis Unit, Mansoura University, Mansoura, Egypt.
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4
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Ankawi G, Tangirala N, Jesudason S, Hladunewich MA. Pregnancy in Patients Receiving Home Dialysis. Clin J Am Soc Nephrol 2024:01277230-990000000-00350. [PMID: 38285469 DOI: 10.2215/cjn.0000000000000437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 01/24/2024] [Indexed: 01/30/2024]
Abstract
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.
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Affiliation(s)
- Ghada Ankawi
- Division of Nephrology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nishanta Tangirala
- Renal Department, Lyell McEwen Hospital, Adelaide, South Australia, Australia
| | - Shilpanjali Jesudason
- Central Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital and School of Medicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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5
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Carvão J, Calhau A, Resende L, Vida C, Silva F, Vieira P, Silva G. A rare case of two successful pregnancies in a female patient on hemodialysis. Nefrologia 2024; 44:107-109. [PMID: 36517359 DOI: 10.1016/j.nefroe.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/16/2022] [Indexed: 06/17/2023] Open
Affiliation(s)
- João Carvão
- Nephrology Department, Hospital Central do Funchal, Funchal, Portugal.
| | - Ana Calhau
- Obstetrics and Gynaecology Department, Hospital Central do Funchal, Funchal, Portugal
| | - Luís Resende
- Nephrology Department, Hospital Central do Funchal, Funchal, Portugal
| | - Carlota Vida
- Nephrology Department, Hospital Central do Funchal, Funchal, Portugal
| | - Francisca Silva
- Nephrology Department, Hospital Central do Funchal, Funchal, Portugal
| | - Pedro Vieira
- Nephrology Department, Hospital Central do Funchal, Funchal, Portugal
| | - Gil Silva
- Nephrology Department, Hospital Central do Funchal, Funchal, Portugal
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6
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Copur S, Berkkan M, Basile C, Cozzolino M, Kanbay M. Dialysis in Pregnancy: An Update Review. Blood Purif 2023; 52:686-693. [PMID: 37379824 DOI: 10.1159/000531157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/11/2023] [Indexed: 06/30/2023]
Abstract
Chronic kidney disease and end-stage kidney disease (ESKD) are important public health problems with increased rates of morbidity, mortality, and social costs. Pregnancy is rare in patients with ESKD, with reduced fertility rates in women undergoing dialysis. Although current advances have led to an increase in live births in pregnant dialysis patients, this modality still has an increased risk of multiple adverse events in pregnant women. Despite these existing risks, large-scale studies investigating the management of pregnant women on dialysis are lacking, resulting in the absence of consensus guidelines for this patient group. In this review, we aimed to present the effects of dialysis during pregnancy. We first discuss pregnancy outcomes in dialysis patients and the development of acute kidney injury during pregnancy. Then, we discuss our recommendations for the management of pregnant dialysis patients, including the maintenance of pre-dialysis blood urea nitrogen levels, the ideal frequency and duration of hemodialysis sessions, as well as the modality of renal replacement therapies, the difficulty of maintaining peritoneal dialysis in the third trimester of pregnancy, and optimization of prepregnancy modifiable risk factors. Finally, we present our recommendations for future studies investigating dialysis among pregnant patients.
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Affiliation(s)
- Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Metehan Berkkan
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Carlo Basile
- Associazione Nefrologica Gabriella Sebastio, Martina Franca, Italy
| | - Mario Cozzolino
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milano, Italy
| | - Mehmet Kanbay
- Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
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7
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Kazory A. Pregnancy in end-stage kidney disease: Great news that needs to be handled carefully. Hemodial Int 2023; 27:E29-E32. [PMID: 36924210 DOI: 10.1111/hdi.13079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/26/2023] [Accepted: 02/28/2023] [Indexed: 03/18/2023]
Abstract
Compared to women with normal kidney function, women with end-stage kidney disease (ESKD) are much less likely to become pregnant, but more likely to have a complicated pregnancy. While renal transplantation remains the best option for women who desire to have a child, pregnancy on dialysis should be considered an option for those who may not receive a transplant during their reproductive years. Many physicians do not encounter a pregnant patient with ESKD during their nephrology training, and may not feel prepared to provide care for such patients in a busy practice. In this paper, we briefly provide an overview of the most significant practical points related to management of a pregnant patient with ESKD through a real-life case with twin pregnancy. The two key elements in management of these patients would be an intensified hemodialysis regimen and a multidisciplinary team that can provide frequent, regular, and multifaceted assessments.
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Affiliation(s)
- Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, USA
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8
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Mambap AT, Bechem E, Kan KM, Laah SN, Sunjoh F, Ashuntantang GE. Case report: 11 years on hemodialysis with a 4-year-old baby girl: A success story. Front Med (Lausanne) 2023; 9:1091568. [PMID: 36760881 PMCID: PMC9905115 DOI: 10.3389/fmed.2022.1091568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/30/2022] [Indexed: 01/26/2023] Open
Abstract
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.
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Affiliation(s)
- Alex Tatang Mambap
- Department of Clinical Sciences, Faculty of Health Sciences, The University of Bamenda, Bamenda, Cameroon,Bamenda Regional Hospital, Bamenda, Cameroon,*Correspondence: Alex Tatang Mambap,
| | | | - Kate Mafor Kan
- Department of Clinical Sciences, Faculty of Health Sciences, The University of Bamenda, Bamenda, Cameroon,Bamenda Regional Hospital, Bamenda, Cameroon
| | - Sylvain Njoyo Laah
- Department of Clinical Sciences, Faculty of Health Sciences, The University of Bamenda, Bamenda, Cameroon,Bamenda Regional Hospital, Bamenda, Cameroon
| | | | - Gloria Enow Ashuntantang
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
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9
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[Outcome of neonates born to mothers with chronic kidney disease]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2023; 25:104-108. [PMID: 36655672 PMCID: PMC9893822 DOI: 10.7499/j.issn.1008-8830.2207017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
About 3% of pregnant women suffer from chronic kidney disease (CKD). This article reviews the literature on the outcomes of neonates born to mothers with CKD (including those undergoing dialysis and kidney transplantation), and the results show that CKD during pregnancy may increase the risk of preterm birth, low birth weight, and small for gestational age infant, but it does not increase the risk of congenital anomalies. As for long-term outcomes, CKD during pregnancy has no significant impact on offspring's physical development and immune function. Neurodevelopmental outcome of offspring is associated with preterm birth and low birth weight, rather than intrauterine drug exposure. However, further research and follow-up are needed to investigate the outcome of neonates born to mothers with CKD.
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10
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Pellé G, Jalal Eddine A, Rieu P, Attias J, Fay S, Hertig A. Success of Pregnancy in a Patient on High-Volume Hemodiafiltration with Citrate-Acidified Dialysate. Case Rep Nephrol Dial 2023; 13:15-19. [PMID: 37013153 PMCID: PMC10066502 DOI: 10.1159/000528725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/29/2022] [Indexed: 04/03/2023] Open
Abstract
Although pregnancy in dialysis patients is rare, recent reports in the literature have shown improvement in pregnancy outcome in this population. Increasing doses of dialysis have led to improvement in fetal prognosis, but recommendations are still lacking, and there are few documented reports of pregnant woman on high-volume online hemodiafiltration. Here, we report the first successful pregnancy in a 28-year-old patient on daily high-volume online post-dilution hemodiafiltration with a citrate dialysate. At 37 weeks and 1 day, she delivered a healthy 2.3 kg baby that did not require neonatal intensive care. This case report suggests that hemodiafiltration with a dialysate acidified with citrate is safe in pregnancy. Further reports and a registry are necessary to confirm that high-volume online hemodiafiltration with a citrate dialysate should be the preferred dialysis modality in pregnant women.
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Affiliation(s)
- Gaëlle Pellé
- Department of Nephrology, Foch Hospital, Suresnes, France
| | | | | | | | - Stephanie Fay
- Department Gynecology, Foch Hospital, Suresnes, France
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11
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Martimbianco ALC, Moreira RDFC, Pacheco RL, Latorraca CDOC, Dos Santos APP, Logullo P, Riera R. Efficacy and safety of hemodialysis strategies for pregnant women with chronic kidney disease: Systematic review. Semin Dial 2023; 36:3-11. [PMID: 35934871 DOI: 10.1111/sdi.13120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 06/28/2022] [Accepted: 07/10/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Ana Luiza Cabrera Martimbianco
- Núcleo de Ensino e Pesquisa e Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-SBEATS), Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Núcleo de Avaliação de Tecnologias em Saúde, Hospital Sírio-Libanês (NATS-HSL), São Paulo, SP, Brazil.,Programa de Pós-graduação em Saúde e Meio Ambiente, Universidade Metropolitana de Santos (UNIMES), Santos, SP, Brazil
| | - Roberta de Fátima Carreira Moreira
- Núcleo de Ensino e Pesquisa e Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-SBEATS), Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Núcleo de Avaliação de Tecnologias em Saúde, Hospital Sírio-Libanês (NATS-HSL), São Paulo, SP, Brazil.,Universidade Federal de São Carlos (UFSCar), São Carlos, SP, Brazil
| | - Rafael Leite Pacheco
- Núcleo de Ensino e Pesquisa e Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-SBEATS), Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Núcleo de Avaliação de Tecnologias em Saúde, Hospital Sírio-Libanês (NATS-HSL), São Paulo, SP, Brazil.,Centro Universitário São Camilo (CUSC), São Paulo, SP, Brazil.,Núcleo de Avaliação de Tecnologias em Saúde, Associação Paulista para o Desenvolvimento da Escola Paulista de Medicina (NATS-SPDM), São Paulo, SP, Brazil
| | - Carolina de Oliveira Cruz Latorraca
- Núcleo de Ensino e Pesquisa e Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-SBEATS), Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Núcleo de Avaliação de Tecnologias em Saúde, Associação Paulista para o Desenvolvimento da Escola Paulista de Medicina (NATS-SPDM), São Paulo, SP, Brazil
| | - Ana Paula Pires Dos Santos
- Núcleo de Ensino e Pesquisa e Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-SBEATS), Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brazil
| | - Patrícia Logullo
- Núcleo de Ensino e Pesquisa e Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-SBEATS), Universidade Federal de São Paulo, São Paulo, SP, Brazil.,UK EQUATOR Network Centre, University of Oxford, Oxford, UK
| | - Rachel Riera
- Núcleo de Ensino e Pesquisa e Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-SBEATS), Universidade Federal de São Paulo, São Paulo, SP, Brazil.,Núcleo de Avaliação de Tecnologias em Saúde, Hospital Sírio-Libanês (NATS-HSL), São Paulo, SP, Brazil.,Escola Paulista de Medicina, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
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12
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Baouche H, Jais JP, Meriem S, Kareche M, Moranne O, Vigneau C, Couchoud C. Pregnancy in women on chronic dialysis in the last decade (2010-2020): a systematic review. Clin Kidney J 2022; 16:138-150. [PMID: 36726433 PMCID: PMC9871848 DOI: 10.1093/ckj/sfac204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Indexed: 02/04/2023] Open
Abstract
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.
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Affiliation(s)
| | - Jean-Philippe Jais
- Department of Biostatistics, APHP–Necker–Enfants Malades Hospital, REIN Registry, University of Paris Cité, Paris, France
| | - Samy Meriem
- Department of Biostatistics, APHP–Necker–Enfants Malades Hospital, Paris, France
| | | | - Olivier Moranne
- Service Nephrologie–Dialyse–Apherese, Hopital Universitaire de Nimes, CHU Caremeau Nîmes, France,IDESP, UMR, Université de Montpellier, France
| | - Cécile Vigneau
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) –UMR S1085, Rennes, France
| | - Cécile Couchoud
- REIN Registry, Agence de la biomédecine, Saint Denis La Plaine, France
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Bakhritdinov FS, Matkarimov ZT, Azimova MT, Saatova UM, Komilova DN, Elmurodova NB. Features of Pregnancy Management in Kidney Transplant Recipients. EXP CLIN TRANSPLANT 2022; 20:92-97. [DOI: 10.6002/ect.donorsymp.2022.o29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Seed E, Gilbertson E. Dialysis and a plant-based diet to achieve physiologic urea levels for fetal benefit: Normal pregnancy outcome despite chronic kidney disease and hypertension. Obstet Med 2022. [DOI: 10.1177/1753495x221110821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes. A growing body of evidence suggests that intensive dialysis, achieving physiologic pre-dialysis blood urea, is associated with decreased morbidity. We report a case of a successful pregnancy outcome in a 32-year-old nulliparous woman with stage 4 chronic kidney disease who dialysed from 11 to 31 weeks, gestation for fetal benefit and concurrently trialled a plant-based diet. We hypothesise that her dietary changes assisted with urea reduction, enabling her to become dialysis independent. Although we must recognise that such pregnancies remain high risk, as demonstrated both in this case and more recent literature, advances in complex obstetric care and dialysis protocols may now give women with chronic kidney disease a realistic hope of a successful pregnancy.
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Affiliation(s)
- Emma Seed
- Department of Obstetrics and Gynaecology, Sunshine Coast Hospital and Health Service, Birtinya, Australia
- School of Medicine and Dentistry, Griffith University, Birtinya, Australia
| | - Elise Gilbertson
- Department of Obstetrics and Gynaecology, Sunshine Coast Hospital and Health Service, Birtinya, Australia
- School of Medicine and Dentistry, Griffith University, Birtinya, Australia
- Department of General Medicine, Sunshine Coast Hospital and Health Service, Birtinya, Australia
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Jesudason S, Williamson A, Huuskes B, Hewawasam E. Parenthood with kidney failure: Answering questions patients ask about pregnancy. Kidney Int Rep 2022; 7:1477-1492. [PMID: 35812283 PMCID: PMC9263253 DOI: 10.1016/j.ekir.2022.04.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 11/30/2022] Open
Abstract
Achieving parenthood can be an important priority for women and men with kidney failure. In recent decades, the paradigm has shifted toward greater support of parenthood, with advances in our understanding of risks related to pregnancy and improvements in obstetrical and perinatal care. This review, codesigned by people with personal experience of kidney disease, provides guidance for nephrologists on how to answer the questions most asked by patients when planning for parenthood. We focus on important issues that arise in preconception counseling for women receiving dialysis and postkidney transplant. We summarize recent studies reflecting pregnancy outcomes in the modern era of nephrology, obstetrical, and perinatal care in developed countries. We present visual aids to help clinicians and women navigate pregnancy planning and risk assessment. Key principles of pregnancy management are outlined. Finally, we explore outcomes of fatherhood in males with kidney failure.
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16
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Dumanski SM, Eckersten D, Piccoli GB. Reproductive Health in Chronic Kidney Disease: The Implications of Sex and Gender. Semin Nephrol 2022; 42:142-152. [PMID: 35718362 DOI: 10.1016/j.semnephrol.2022.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Chronic kidney disease (CKD) is frequently accompanied by reproductive health challenges in females and males alike. Progression of CKD is associated with escalating impairment of the hypothalamic-pituitary-gonadal axis, which facilitates evolving ovarian, testicular, and sexual dysfunction. Common clinical reproductive health complications in CKD include abnormal menstruation, impaired sexual health, and reduced fertility. Though sex-specific factors, such as sex hormones and gonadal function, have a strong influence on reproductive health outcomes in CKD, a person's gender and gendered experience also have important implications. Institutionalized gender, gendered perceptions of health, and health care-seeking behaviors, as well as adherence to medical care, all have critical effects on reproductive health in CKD. This review endeavors to explore the implications of both sex and gender on overall reproductive health in individuals living with CKD.
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Affiliation(s)
- Sandra M Dumanski
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada; Libin Cardiovascular Institute, Calgary, Canada; Alberta Kidney Disease Network, Alberta, Canada.
| | - Dag Eckersten
- Department of Nephrology, Lund University, Skane University Hospital, Malmo, Sweden
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17
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Determinants of perinatal outcomes in dialysed and transplanted women in Australia. Kidney Int Rep 2022; 7:1318-1331. [PMID: 35685315 PMCID: PMC9171625 DOI: 10.1016/j.ekir.2022.03.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/11/2022] [Indexed: 12/17/2022] Open
Abstract
Introduction Drivers of adverse perinatal outcomes in pregnancies of women receiving chronic kidney replacement therapy (KRT) remain poorly understood. Methods Births ≥ 20 weeks of gestation in Australian women receiving KRT were analyzed for perinatal outcomes stratified by maternal KRT exposure (dialysis or transplant, analyzed separately), by linking the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and perinatal data sets (1991–2013). Results Of 2,948,084 babies (1,628,181 mothers), 248 were born to mothers receiving KRT (transplant, n = 211; dialysis, n = 37), with live birth rates ≥ 94%. The perinatal death rate was 162, 62, and 9 per 1000 births in the dialysis, transplant, and non-KRT cohorts, respectively. Babies exposed to KRT had increased odds of prematurity, small-for-gestational age (SGA), poor birth condition, resuscitation, intensive care admission, and longer hospitalization, with the dialysis cohort having worse outcomes. Preterm babies of dialyzed and transplanted mothers (compared with preterm babies with no KRT exposure) experienced 1.6- to 2.7-fold higher odds for all adverse outcomes, except birthweight < 2500 g, which was 11-fold higher for the dialysis cohort. In adjusted analyses, transplanted women with better allograft function (serum creatinine ≤ 120 μmol/l) still had >10-fold higher odds of preterm birth and low birthweight and 1.8- to 4.6-fold increased odds of other adverse outcomes. In transplanted women, mediation analysis revealed that pregnancy-induced hypertension contributed only a modest proportional effect (2.5%–11.2%) on adverse outcomes. Conclusion Maternal dialysis and transplantation conferred excess perinatal morbidity, particularly for preterm babies, and even in women with good preconception allograft function. Pregnancy-induced hypertension is not the predominant determinant of perinatal morbidity. Preconception counseling of women with kidney disease should encompass discussion of perinatal complications.
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Carvão J, Calhau A, Resende L, Vida C, Silva F, Vieira P, Silva G. A rare case of two successful pregnancies in a female patient on hemodialysis. Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hendren EM, Reynolds ML. Pregnancy in Renal Transplant Recipients: Histopathology Provides New Insight. Kidney Int Rep 2022; 7:6-8. [PMID: 35005307 PMCID: PMC8720824 DOI: 10.1016/j.ekir.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Elizabeth M. Hendren
- Center for Glomerular Diseases, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Monica L. Reynolds
- UNC Kidney Center, Division of Nephrology and Hypertension, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Oliverio AL, Bramham K, Hladunewich MA. Pregnancy and CKD: Advances in Care and the Legacy of Dr Susan Hou. Am J Kidney Dis 2021; 78:865-875. [PMID: 34656369 DOI: 10.1053/j.ajkd.2021.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/13/2021] [Indexed: 11/11/2022]
Abstract
Dr Susan Hou began her illustrious nephrology career at a time when pregnancy in women with chronic kidney disease (CKD) was hazardous and actively discouraged. Her pioneering research in women's health provided much of the early outcome data that shaped our current understanding of CKD and pregnancy. Although many uncertainties regarding optimal management of this vulnerable patient group remain, recent decades have witnessed important advances and renewed interest in improving care for pregnant women with CKD. Many nephrologists have been inspired by Dr Hou's lifetime of work and are grateful for her generous collaborations. In this In Practice Review, we honor her legacy by providing an update of current literature and clinical management guidance in the context of a clinical case vignette that challenges us to consider the many complex aspects to the counseling and care of women with CKD who desire a pregnancy.
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Affiliation(s)
- Andrea L Oliverio
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London, United Kingdom; Department of Renal Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Michelle A Hladunewich
- Divisions of Nephrology and Obstetrics, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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21
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Pregnancy and delivery in women receiving maintenance hemodialysis in Japan: analysis of potential risk factors for neonatal and maternal complications. J Nephrol 2021; 34:1599-1609. [PMID: 34591251 PMCID: PMC8494660 DOI: 10.1007/s40620-021-01146-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 08/16/2021] [Indexed: 11/18/2022]
Abstract
Introduction Average dialysis vintage in Japan is among the longest in the world, providing a unique opportunity to characterize pregnancy under conditions of long dialysis vintage. In 2017, we carried out a nationwide survey following up on a similar survey in 1996, in which we investigated the prevalence and outcomes of pregnancy in women undergoing dialysis and assessed risk factors associated with neonatal and maternal complications. Methods The target population was women aged 15–44 years undergoing maintenance dialysis between 2012 and 2016. The survey was conducted in 2693 dialysis units. Results A response was obtained from 951 dialysis units, yielding a target population of 1992 women of childbearing age receiving hemodialysis or peritoneal dialysis. Pregnancy occurred only among women receiving hemodialysis, with 25 pregnancies (1.26% in 5 years) being reported for 20 women. Detailed information about 19 pregnancies (mean age 34.6 ± 5.7 years at conception, mean dialysis vintage 8.4 ± 7.3 years) indicated 4 spontaneous abortions, 1 elective abortion, no neonatal deaths, and 14 surviving infants, including 5 full-term (≥ 37 weeks at birth), 2 late preterm (34–36), and 3 extremely preterm (< 28) cases. Neonatal complications occurred in the offspring of 3 mothers who had end-stage renal disease (ESRD) caused by primary glomerulonephritis and serum albumin levels (sAlb) ≤ 3.2 mg/dL in the first trimester. These mothers had started dialysis at 12, 17, and 30 years of age. ESRD caused by diabetic nephropathy or primary glomerulonephritis, age at conception ≥ 38 years, and sAlb ≤ 3.2 mg/dL were associated with maternal complications, although not significantly. Conclusions In this study, the pregnancy rate of Japanese women with ESRD was 0.25% per year. The study generates the hypothesis that ESRD caused by diabetic nephropathy and age at conception ≥ 38 years are potential risk factors for maternal complications but not for neonatal complications in dialysis patients, and that hypoalbuminemia is a potential risk factor for both kinds of complications. Graphic Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01146-3.
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22
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Álvarez-Villarreal M, Velarde-García JF, García-Bravo C, Carrasco-Garrido P, Jimenez-Antona C, Moro-Lopez-Menchero P, Palacios-Ceña D. The experience of being a mother with end stage renal disease: A qualitative study of women receiving treatment at an ambulatory dialysis unit. PLoS One 2021; 16:e0257691. [PMID: 34570806 PMCID: PMC8476019 DOI: 10.1371/journal.pone.0257691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022] Open
Abstract
Background End-stage kidney disease (ESKD) has considerable effects on the quality of life, impairing daily activities and leading to lifestyle changes. The purpose of this study was therefore to explore the experience of motherhood and taking care of children in women with ESKD. Methods A qualitative exploratory study was conducted based on an interpretive framework. Participants were recruited using non-probabilistic purposeful sampling. In total, 14 women with ESKD were included, who were treated at the dialysis unit of a Spanish hospital. In-depth interviews (unstructured and semi-structured interviews) and researchers’ field notes were used to collect the data. A systematic text condensation analysis was performed. The techniques performed and application procedures used to control trustworthiness were credibility, transferability, dependability, and confirmability. Results Three themes emerged from the data. “Coping with being a mother” described how women are faced with the decision to become mothers and assess the risks of pregnancy. The second theme, called “Children and the experience of illness”, highlighted the women’s struggle to prevent the disease from affecting their children emotionally or disrupting their lives. The third theme, “Fear of genetic transmission”, was based on the women’s fear of passing the disease on to their children. Conclusions Deciding to become a mother and taking care of children represents a challenge for women with ESKD, coupled with the losses in their lives caused by the disease. These findings are only relevant to women on dialysis.
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Affiliation(s)
| | - Juan Francisco Velarde-García
- Department of Nursing, Spanish Red Cross, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Autonoma de Madrid, Madrid, Spain
- * E-mail:
| | - Cristina García-Bravo
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Research Group in Evaluation and Assessment of Capacity, Functionality and Disability of Universidad Rey Juan Carlos (TO+IDI), Alcorcón, Spain
| | - Pilar Carrasco-Garrido
- Department of Medical Specialties and Public Health, Universidad Rey Juan Carlos, Alcorcón, Spain
| | - Carmen Jimenez-Antona
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Research Group of Humanities and Qualitative Research in Health Science of Universidad Rey Juan Carlos (Hum&QRinHS), Alcorcón, Spain
| | - Paloma Moro-Lopez-Menchero
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Research Group of Humanities and Qualitative Research in Health Science of Universidad Rey Juan Carlos (Hum&QRinHS), Alcorcón, Spain
| | - Domingo Palacios-Ceña
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Research Group of Humanities and Qualitative Research in Health Science of Universidad Rey Juan Carlos (Hum&QRinHS), Alcorcón, Spain
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Gouveia IF, Silva JR, Santos C, Carvalho C. Maternal and fetal outcomes of pregnancy in chronic kidney disease: diagnostic challenges, surveillance and treatment throughout the spectrum of kidney disease. ACTA ACUST UNITED AC 2021; 43:88-102. [PMID: 33460427 PMCID: PMC8061969 DOI: 10.1590/2175-8239-jbn-2020-0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/31/2020] [Indexed: 01/01/2023]
Abstract
Pregnancy requires several physiological adaptations from the maternal organism, including modifications in the glomerular filtration rate and renal excretion of several products. Chronic kidney disease (CKD) can negatively affect these modifications and consequently is associated with several adverse maternal and fetal adverse outcomes (gestational hypertension, progression of renal disease, pre-eclampsia, fetal growth restriction, and preterm delivery). A multidisciplinary vigilance of these pregnancies is essential in order to avoid and/or control the harmful effects associated with this pathology. Dialysis and transplantation can decrease the risks of maternal and fetal complications, nonetheless, the rates of complications remain high comparing with a normal pregnancy. Several recent developments in this area have improved quality and efficacy of treatment of pregnant women with CKD. This article summarizes the most recent literature about CKD and pregnancy.
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Affiliation(s)
- Inês Filipe Gouveia
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Joana Raquel Silva
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Clara Santos
- Serviço de Nefrologia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Claudina Carvalho
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
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The Possibility of Using Bioelectrical Impedance Analysis in Pregnant and Postpartum Women. Diagnostics (Basel) 2021; 11:diagnostics11081370. [PMID: 34441305 PMCID: PMC8391189 DOI: 10.3390/diagnostics11081370] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/22/2021] [Accepted: 07/29/2021] [Indexed: 12/14/2022] Open
Abstract
Pregnancy is a time of significant changes occurring in the composition of a woman’s body in order to provide support for the growth and development of the foetus. Bioelectrical impedance analysis (BIA) is used to assess the body composition and hydration status. This technique represents a non-invasive, reliable, and fast clinical approach, which is well tolerated by patients. A segmental impedance measurement might be advantageous in pregnant women, particularly in late pregnancy. The purpose of this paper is to provide a review of different applications of BIA in pregnant and postpartum women. It seems that BIA has a better prognostic potential for gestational and post-partum outcomes than body mass index. The BIA method can be successfully used to study the effect of excessive gestational weight gain in pregnancy on the development of obstetric complications. Studying the mother’s body composition and correlating it with her energy balance could facilitate the development of dietary recommendations for women. Evaluation of the body composition can provide important clues for diagnosis of gestational diabetes mellitus in pregnant women with a low risk of this disease. BIA is also used as one of the additional tests in assessing the risk of developing gestational hypertension and preeclampsia.
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Hernández García E, Borrego García E, Díaz Gómez L, Navas-Parejo Casado A, Prados Garrido MD. Biochemical parameters of a newborn from a mother in hemodialysis after an inadequate session. A case reported. Nefrologia 2021; 41:480-482. [PMID: 36165121 DOI: 10.1016/j.nefroe.2020.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/31/2020] [Indexed: 06/16/2023] Open
Affiliation(s)
| | - Elena Borrego García
- Servicio de Nefrología, Hospital Universitario Clínico San Cecilio, Granada, Spain
| | - Lidia Díaz Gómez
- Servicio de Nefrología, Hospital Universitario Clínico San Cecilio, Granada, Spain
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Lavie A, Czuzoj-Shulman N, Spence AR, Abenhaim HA. Characteristics and outcomes among pregnant women with end-stage renal disease on hemodialysis. J Matern Fetal Neonatal Med 2021; 35:5897-5903. [PMID: 34030571 DOI: 10.1080/14767058.2021.1900106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE Pregnancy among women with end-stage renal disease (ESRD) has risen in frequency, which may be attributed to improvements in hemodialysis care. Our objective was to describe baseline characteristics and pregnancy outcomes among women with ESRD on hemodialysis. METHODS Using the United States' Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we created a cohort of women with ESRD on hemodialysis who gave birth between 2005 and 2015. We determined the proportion of adverse maternal and neonatal outcomes among this cohort. Then, we created a composite measure of vascular-mediated adverse pregnancy outcomes. Women who experienced at least one of either preeclampsia, intrauterine growth restriction, or intrauterine fetal death were categorized as having the composite measure. Then, multivariate regression models were used to estimate the associations between maternal baseline demographic and clinical characteristics and the composite measure. RESULTS Among 8,765,973 deliveries between 2005 and 2015, 307 were to women with ESRD on hemodialysis. Over the study period, the incidence of pregnancies to women with ESRD increased from 0.47 to 5.76/100,000 births. An estimated 28% of pregnancies were complicated by preeclampsia, 8% by placental abruption, 58% delivered by cesarean, and in the postpartum, 28% required blood transfusions and 6% experienced sepsis. About 45% of babies were born preterm and 14% had IUGR. The composite measure of adverse events was not found to be associated with any baseline maternal characteristics. CONCLUSIONS The frequency of pregnant women with ESRD on hemodialysis has risen, with adverse pregnancy complications for both mother and fetus. Transfer to high-risk centers is suggested for women with ESRD.
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Affiliation(s)
- Anat Lavie
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Canada
| | - Nicholas Czuzoj-Shulman
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Canada
| | - Andrea R Spence
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Canada
| | - Haim Arie Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Canada.,Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Canada
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Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2020010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.
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Dialysis on Pregnancy: An Overview. WOMEN 2021. [DOI: 10.3390/women1010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Madazlı R, Kaymak D, Alpay V, Mahmudova A, Seyahi N. Evaluation of obstetric outcomes and prognostic factors in pregnancies with chronic kidney disease. Hypertens Pregnancy 2021; 40:75-80. [PMID: 33393398 DOI: 10.1080/10641955.2020.1869249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: To evaluate the obstetric outcomes of pregnancies with chronic kidney disease (CKD) and to assess the prognostic factors on adverse obstetric outcomes. Methods: We retrospectively reviewed 101 singleton pregnancies with CKD. Obstetric outcomes were explored according to CKD stages. The composite adverse obstetric outcome was defined as at least one of stillbirth, neonatal death and delivery <34 weeks due to preeclampsia or fetal distress. Results: The incidences of preeclampsia, fetal growth restriction, perinatal mortality and composite adverse obstetric outcome were 40.5%, 26.7%, 14.8% and 37.6% respectively in pregnancies with CKD. Composite obstetric adverse outcome was significantly higher in pregnancies with CKD stage 4-5 than the other stages (p < 0.01). CKD stage 4-5 and baseline proteinuria >3 g/24 h were associated with composite obstetric adverse outcome (OR 43.2, p = 0.005 and OR 6.08, p = 0.01 respectively) comparing to stage 1 and proteinuria <0.5 g/24 h. Conclusion: Incidences of adverse obstetric outcomes are high even in early stages of CKD. CKD stage 4-5 and baseline proteinuria >3 g/24 h are poor prognostic factors.
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Affiliation(s)
- Riza Madazlı
- Cerrahpasa Medical Faculty, Department of Obstetrics and Gynecology, Istanbul University-Cerrahpasa , Istanbul, Turkey
| | - Didem Kaymak
- Cerrahpasa Medical Faculty, Department of Obstetrics and Gynecology, Istanbul University-Cerrahpasa , Istanbul, Turkey
| | - Verda Alpay
- Cerrahpasa Medical Faculty, Department of Obstetrics and Gynecology, Istanbul University-Cerrahpasa , Istanbul, Turkey
| | - Aytac Mahmudova
- Cerrahpasa Medical Faculty, Department of Obstetrics and Gynecology, Istanbul University-Cerrahpasa , Istanbul, Turkey
| | - Nurhan Seyahi
- Cerrahpasa Medical Faculty, Department of Nephrology, Istanbul University-Cerrahpasa , Istanbul, Turkey
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Oliverio AL, Hladunewich MA. End-Stage Kidney Disease and Dialysis in Pregnancy. Adv Chronic Kidney Dis 2020; 27:477-485. [PMID: 33328064 DOI: 10.1053/j.ackd.2020.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 12/20/2022]
Abstract
End-stage kidney disease is associated with low fertility, with rates of conception in women on dialysis estimated at 1/100th of the general population. However, live birth rates are increasing over time in women on hemodialysis, whereas they remain lower and static in women on peritoneal dialysis. Intensification of hemodialysis, targeting a serum blood urea nitrogen <35 mg/dL or 36 hours of dialysis per week in women with no residual kidney function, is associated with improved live birth rates and longer gestational age. Even in intensively dialyzed cohorts, rates of prematurity and need for neonatal intensive care are high, upwards of 50%. Although women on peritoneal dialysis in pregnancy do not appear to be at increased risk of delivering preterm compared with those on hemodialysis, their infants are more likely to be small for gestational age. As such, hemodialysis has emerged as the preferred dialysis modality in pregnancy. Provision of specialized nephrology, obstetric, and neonatal care is necessary to manage these complex pregnancies and family planning counseling should be offered to all women with end-stage kidney disease.
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Arai H, Mori KP, Yokoi H, Mizuta K, Ogura J, Suginami K, Endo T, Ikeda Y, Matsubara T, Tsukamoto T, Yanagita M. 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. RENAL REPLACEMENT THERAPY 2020. [DOI: 10.1186/s41100-020-00296-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
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.
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Hernández García E, Borrego García E, Díaz Gómez L, Navas-Parejo Casado A, Prados Garrido MD. Biochemical parameters of a newborn from a mother in hemodialysis after an inadequate session. A case reported. Nefrologia 2020. [PMID: 32943242 DOI: 10.1016/j.nefro.2020.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
| | - Elena Borrego García
- Servicio de Nefrología, Hospital Universitario Clínico San Cecilio, Granada, España
| | - Lidia Díaz Gómez
- Servicio de Nefrología, Hospital Universitario Clínico San Cecilio, Granada, España
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Abstract
There has been a good deal of discussion in the literature regarding which subjects are vulnerable in the context of clinical trials. There has been significantly less discussion regarding when and how to include vulnerable subjects in clinical trials. This lack of guidance is a particular problem for trials covered by the US regulations, which mandate strict requirements on the inclusion of three groups: pregnant women/fetuses, prisoners, and children. For the past 30 years, funders, investigators, and institutional review boards have frequently responded to these regulations by excluding pregnant women/fetuses, prisoners, and children from clinical trials. More recent work has emphasized the extent to which a default of exclusion can undermine the value of clinical trials, especially pragmatic trials. A default of exclusion also has the potential to undermine the interests of vulnerable groups, in both the short and the long term. These concerns raise the need for guidance on how to satisfy existing US regulations, while minimizing their negative impact on the value of clinical trials and the interests of vulnerable groups. The present manuscript thus describes a six-step decision procedure that institutional review boards can use to determine when and how to include vulnerable subjects in clinical trials, including pragmatic trials, that are covered by US regulations.
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Affiliation(s)
- David Wendler
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
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Chaker H, Masmoudi S, Toumi S, Dammak N, Hachicha J, Kammoun K, Yaich S, Hmida MB. [Pregnancy in patients on chronic haemodialysis: about 25 cases which occurred in the south of Tunisia]. Pan Afr Med J 2020; 36:195. [PMID: 32952839 PMCID: PMC7467613 DOI: 10.11604/pamj.2020.36.195.20514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/10/2019] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Hanen Chaker
- Unité de Recherche de Pathologie Rénale, Service de Néphrologie, Faculté de Médecine, CHU Hedi Chaker, Sfax, Tunisie
| | - Slim Masmoudi
- Unité de Recherche de Pathologie Rénale, Service de Néphrologie, Faculté de Médecine, CHU Hedi Chaker, Sfax, Tunisie
| | - Salma Toumi
- Unité de Recherche de Pathologie Rénale, Service de Néphrologie, Faculté de Médecine, CHU Hedi Chaker, Sfax, Tunisie
| | - Najla Dammak
- Unité de Recherche de Pathologie Rénale, Service de Néphrologie, Faculté de Médecine, CHU Hedi Chaker, Sfax, Tunisie
| | - Jamil Hachicha
- Unité de Recherche de Pathologie Rénale, Service de Néphrologie, Faculté de Médecine, CHU Hedi Chaker, Sfax, Tunisie
| | - Khawla Kammoun
- Unité de Recherche de Pathologie Rénale, Service de Néphrologie, Faculté de Médecine, CHU Hedi Chaker, Sfax, Tunisie
| | - Soumaya Yaich
- Unité de Recherche de Pathologie Rénale, Service de Néphrologie, Faculté de Médecine, CHU Hedi Chaker, Sfax, Tunisie
| | - Mohamed Ben Hmida
- Unité de Recherche de Pathologie Rénale, Service de Néphrologie, Faculté de Médecine, CHU Hedi Chaker, Sfax, Tunisie
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Hashimoto S, Maoka T, Yamamoto R, Kawashima K, Nishikawa A, Sakurada K, Koike T, Shigematsu T. Comparison of bioelectrical impedance analysis in healthy pregnant women and patient on hemodialysis. Ther Apher Dial 2020; 25:160-165. [PMID: 32475042 DOI: 10.1111/1744-9987.13530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/24/2020] [Accepted: 05/27/2020] [Indexed: 11/28/2022]
Abstract
Pregnant woman undergoing dialysis face challenges such as miscarriage and stillbirth when carrying a baby to term. A complication of prenatal care is the difficulty in properly managing body fluids. We compare fluid volumes between healthy pregnant women and two pregnant women undergoing dialysis using bioelectrical impedance analysis (BIA). Data of 52 healthy pregnant women at various stages of their pregnancy were analyzed for the study. We included these many cases so as to collect sufficient data to compare them with our two cases of women undergoing dialysis who successfully completed their term deliveries. Fluid volumes were measured every week before and after dialysis using BIA. We also measured the levels of human atrial natriuretic peptide after dialysis. During dialysis, the dry weight (DW) of pregnant patients is altered based on the state of the amniotic fluid and fetus. However, evaluating body fluid and DW using radiography is difficult in pregnant women. BIA offers a mostly harmless alternative for such measurements. Using BIA, we were able to easily measure body fluid volume and change the setting of DW for dialysis. Thus, our successful example can serve as a reference for future cases of pregnant women undergoing dialysis. Nevertheless, given that the state of the fetus and amniotic fluid affect the results of dialysis, it is important that we use not only BIA but also a comprehensive evaluation to determine dialysis settings in pregnant women.
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Affiliation(s)
- Seiji Hashimoto
- Department of Nephrology, Kinan Hospital, Tanabe, Wakayama, Japan
| | - Tomochika Maoka
- Department of Nephrology, NTT East Japan Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Rie Yamamoto
- Department of Nephrology, NTT East Japan Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Keisuke Kawashima
- Department of Nephrology, NTT East Japan Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Akira Nishikawa
- Department of Obstetrics and Gynecology, NTT East Japan Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Katsumi Sakurada
- Faculty of Clinical Engineering, NTT East Japan Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Takao Koike
- Department of Internal Medicine, NTT East Japan Sapporo Hospital, Sapporo, Hokkaido, Japan
| | - Takashi Shigematsu
- Department of Nephrology, Wakayama Medical University, Tanabe, Wakayama, Japan
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Esposito P, Garibotto G, Picciotto D, Costigliolo F, Viazzi F, Conti NE. Nutritional Challenges in Pregnant Women with Renal Diseases: Relevance to Fetal Outcomes. Nutrients 2020; 12:nu12030873. [PMID: 32213942 PMCID: PMC7146629 DOI: 10.3390/nu12030873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023] Open
Abstract
Pregnancy in women affected by chronic kidney disease (CKD) has become more common in recent years, probably as a consequence of increased CKD prevalence and improvements in the care provided to these patients. Management of this condition requires careful attention since many clinical aspects have to be taken into consideration, including the reciprocal influence of the renal disease and pregnancy, the need for adjustment of the medical treatments and the high risk of maternal and obstetric complications. Nutrition assessment and management is a crucial step in this process, since nutritional status may affect both maternal and fetal health, with potential effects also on the future development of adult diseases in the offspring. Nevertheless, few data are available on the nutritional management of pregnant women with CKD and the main clinical indications are based on small case series or are extrapolated from the general recommendations for non-pregnant CKD patients. In this review, we discuss the main issues regarding the nutritional management of pregnant women with renal diseases, including CKD patients on conservative treatment, patients on dialysis and kidney transplant patients, focusing on their relevance on fetal outcomes and considering the peculiarities of this population and the approaches that could be implemented into clinical practice.
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Attini R, Grati FR, Menato G, Todros T, Colla L, Rossetti M, Malvestiti B, Alemanno MG, Masturzo B, Piccoli GB, Viora E. Pregnancy on dialysis and with a failing kidney graft: A double challenge for non-invasive prenatal testing. Prenat Diagn 2020; 40:387-389. [PMID: 31916614 DOI: 10.1002/pd.5639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 12/20/2019] [Accepted: 12/26/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Rossella Attini
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza- Sant'Anna Hospital, Torino, Italy
| | - Francesca R Grati
- Research and Development, Cytogenetics and Medical Genetics Unit, TOMA Advanced Biomedical Assays, Impact lab Group, Busto Arsizio (Varese), Italy
| | - Guido Menato
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza- Sant'Anna Hospital, Torino, Italy
| | - Tullia Todros
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza- Sant'Anna Hospital, Torino, Italy
| | - Loredana Colla
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Maura Rossetti
- SCDU Nephrology, Department Città della Salute e della Scienza, University of Torino, Torino, Italy
| | - Barbara Malvestiti
- Research and Development, Cytogenetics and Medical Genetics Unit, TOMA Advanced Biomedical Assays, Impact lab Group, Busto Arsizio (Varese), Italy
| | - Maria G Alemanno
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza- Sant'Anna Hospital, Torino, Italy
| | - Bianca Masturzo
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza- Sant'Anna Hospital, Torino, Italy
| | - Giorgina B Piccoli
- Service de Nephrologie, Centre Hospitalier Le Mans, Le Mans, France.,Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Elsa Viora
- Department of Obstetrics and Gynecology SC2U, Città della Salute e della Scienza- Sant'Anna Hospital, Torino, Italy
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Oliverio AL, Bragg-Gresham JL, Admon LK, Wright Nunes JA, Saran R, Heung M. Obstetric Deliveries in US Women With ESKD: 2002-2015. Am J Kidney Dis 2019; 75:762-771. [PMID: 31785826 DOI: 10.1053/j.ajkd.2019.08.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 08/30/2019] [Indexed: 12/31/2022]
Abstract
RATIONALE & OBJECTIVE Women with end-stage kidney disease (ESKD) have decreased fertility and are at increased risk for pregnancy complications. This study examined secular trends and outcomes of obstetric deliveries in a US cohort of women with ESKD. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Women aged 18 to 44 years with ESKD and registered in the US Renal Data System from 2002 to 2015. EXPOSURE ESKD modality (hemodialysis [HD], peritoneal dialysis, transplantation). OUTCOMES Infant delivery, preterm delivery, cesarean delivery. ANALYTICAL APPROACH Unadjusted delivery rates were expressed as number of delivering women per 1,000 patient-years among women aged 18 to 44 years within each year during the study period, stratified by ESKD modality. Logistic regression models were used to evaluate associations of delivery, preterm delivery, and cesarean delivery with patient characteristics. RESULTS The delivery rate in women undergoing HD and women with a kidney transplant increased from 2.1 to 3.6 and 3.1 to 4.6 per 1,000 patient-years, respectively (P<0.001 for each). The delivery rate in patients undergoing peritoneal dialysis was lower and did not increase significantly (P=0.9). Women with a transplant were less likely to deliver preterm compared with women undergoing HD (OR, 0.92; 95% CI, 0.84-1.00), though more likely have a cesarean delivery (OR, 1.18; 95% CI, 1.06-1.31). For deliveries occurring in the 2012 to 2015 period, 75% of women treated with HD were prescribed 4 or fewer outpatient HD treatments per week and 25% were prescribed 5-plus treatments per week in the 30 days before delivery. LIMITATIONS Ascertainment of outcomes and comorbid conditions using administrative claims data. CONCLUSIONS The delivery rate in women of reproductive age with ESKD increased from 2002 to 2015 among those treated with transplantation or HD. Women with a functioning transplant were less likely to deliver preterm, but more likely to have a cesarean delivery. Prescriptions for outpatient intensified HD for pregnant women with ESKD were infrequent in 2012 to 2015.
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Affiliation(s)
- Andrea L Oliverio
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
| | | | - Lindsay K Admon
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Julie A Wright Nunes
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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Sprenger-Mähr H, Zitt E, Kronbichler A, Cejna M, Lhotta K. A hemodialysis patient with bone disease after pregnancy: a case report. BMC Nephrol 2019; 20:425. [PMID: 31752733 PMCID: PMC6873679 DOI: 10.1186/s12882-019-1603-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/28/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pregnancy is rare in women on hemodialysis. Recommendations for the treatment of secondary hyperparathyroidism (sHPT) and preservation of bone health in pregnant dialysis patients are lacking. CASE PRESENTATION We present the case of a young woman with end-stage kidney disease (ESKD) due to lupus nephritis, who developed multiple brown tumors while on hemodialysis during her second pregnancy. During her first pregnancy sHPT was well controlled and no skeletal complications occurred. Before the second pregnancy she developed severe sHPT. During pregnancy, dialysis time was increased to 24 h per week, the patient was given oral calcitriol, and the dialysate calcium concentration was set at 1.5 mmol/l. In week 20 the patient complained about bone pain in her left hip. Magnetic resonance imaging revealed a cystic lesion compatible with a brown tumor. The baby was delivered in the 36th week by cesarean section. Further assessment identified multiple brown tumors of her skeleton, including the acetabulum, tibia, ribs, skull, thoracic spine and thumb. She required multiple orthopedic surgeries. Three months after pregnancy, etelcalcetide was started, which brought about a gradual improvement in her sHPT. CONCLUSIONS This case demonstrates that the combination of pregnancy and severe sHPT in dialysis patients can have deleterious consequences for bone health.
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Affiliation(s)
- Hannelore Sprenger-Mähr
- Department of Internal Medicine III, Academic Teaching Hospital Feldkirch, Carinagasse 47, Feldkirch, Austria
| | - Emanuel Zitt
- Department of Internal Medicine III, Academic Teaching Hospital Feldkirch, Carinagasse 47, Feldkirch, Austria
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University of Innsbruck, Innsbruck, Austria
| | - Manfred Cejna
- Institute for Diagnostic and Interventional Radiology, Academic Teaching Hospital Feldkirch, Feldkirch, Austria
| | - Karl Lhotta
- Department of Internal Medicine III, Academic Teaching Hospital Feldkirch, Carinagasse 47, Feldkirch, Austria.
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Morisawa H, Hirashima C, Sano M, Nagayama S, Takahashi H, Shirasuna K, Ohkuchi A. Difficulty of predicting early-onset super-imposed preeclampsia in pregnant women with hemodialysis due to diabetic nephropathy by serum levels of sFlt-1, PlGF, and sEng. CEN Case Rep 2019; 9:101-105. [PMID: 31728843 DOI: 10.1007/s13730-019-00435-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 11/02/2019] [Indexed: 11/28/2022] Open
Abstract
There are few case reports in which circulating levels of soluble fms-like tyrosine kinase 1 (sFlt-1), placental growth factor (PlGF), and soluble endoglin (sEng) were measured before the onset of super-imposed preeclampsia in women with hemodialysis. A 40-year-old Japanese nulliparous women with hemodialysis due to diabetic nephropathy became pregnant by frozen embryo transfer. Intensive hemodialysis was started at 5 weeks of gestation. Her blood pressure (BP) in the first trimester was around 130/80 mmHg. At 20+3 weeks, she was admitted for close monitoring; her BP was 137/75 mmHg. Her BP increased to 157/88 mmHg at 31+2 weeks, and nifedipine at 20 mg/day was started at 31+6 weeks. However, the serial longitudinal measurements of sFlt-1, PlGF, and sEng did not predict the onset of super-imposed preeclampsia. Cesarean section was performed at 33+6 weeks due to uncontrollable hypertension. A healthy female infant weighing 2138 g was delivered. As for the changes of biomarkers between just before and just after hemodialysis, sFlt-1 was significantly higher just after compared with just before hemodialysis (5774 ± 1875 pg/mL vs. 2960 ± 905 pg/mL, respectively, p < 0.001). PlGF was also significantly higher just after compared with just before hemodialysis (2227 ± 1038 pg/mL vs. 1377 ± 614 pg/mL, respectively, p < 0.001). However, the sFlt-1/PlGF ratio and sEng levels were not significantly different between just before and just after hemodialysis (p = 0.115, p = 0.672, respectively). In conclusion, prediction of early-onset super-imposed preeclampsia using angiogenic and anti-angiogenic markers in pregnant women with hemodialysis might be difficult.
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Affiliation(s)
- Hiroyuki Morisawa
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Chikako Hirashima
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Miho Sano
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Shiho Nagayama
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Hironori Takahashi
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan
| | - Koumei Shirasuna
- Department of Animal Science, Tokyo University of Agriculture, 1737 Funako, Atsugi-shi, Kanagawa, 243-0034, Japan
| | - Akihide Ohkuchi
- Department of Obstetrics and Gynecology, Jichi Medical University School of Medicine, 3311-1 Yakushiji, Shimotsuke-shi, Tochigi, 329-0498, Japan.
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Wiles K, Chappell L, Clark K, Elman L, Hall M, Lightstone L, Mohamed G, Mukherjee D, Nelson-Piercy C, Webster P, Whybrow R, Bramham K. Clinical practice guideline on pregnancy and renal disease. BMC Nephrol 2019; 20:401. [PMID: 31672135 PMCID: PMC6822421 DOI: 10.1186/s12882-019-1560-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/16/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Kate Wiles
- NIHR Doctoral Research Fellow in Obstetric Nephrology, Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK.
| | - Lucy Chappell
- Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK
| | | | - Louise Elman
- Expert Patient, c/o The Renal Association, Bristol, UK
| | - Matt Hall
- Nottingham University Hospital, Nottingham, UK
| | - Liz Lightstone
- Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Catherine Nelson-Piercy
- Guy's and St. Thomas' NHS Foundation Trust and Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Kate Bramham
- King's College Hospital NHS Foundation Trust and King's College London, London, UK
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Ashby D, Borman N, Burton J, Corbett R, Davenport A, Farrington K, Flowers K, Fotheringham J, Andrea Fox RN, Franklin G, Gardiner C, Martin Gerrish RN, Greenwood S, Hothi D, Khares A, Koufaki P, Levy J, Lindley E, Macdonald J, Mafrici B, Mooney A, Tattersall J, Tyerman K, Villar E, Wilkie M. Renal Association Clinical Practice Guideline on Haemodialysis. BMC Nephrol 2019; 20:379. [PMID: 31623578 PMCID: PMC6798406 DOI: 10.1186/s12882-019-1527-3] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022] Open
Abstract
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
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Affiliation(s)
- Damien Ashby
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England.
| | - Natalie Borman
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | - James Burton
- University Hospitals of Leicester NHS Trust, Leicester, England
| | - Richard Corbett
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | | | - Ken Farrington
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Katey Flowers
- Wessex Kidney Centre, Portsmouth NHS Trust, Portsmouth, England
| | | | - R N Andrea Fox
- School of Nursing and Midwifery, University of Sheffield, Sheffield, England
| | - Gail Franklin
- East & North Hertfordshire NHS Trust, Stevenage, England
| | | | | | - Sharlene Greenwood
- Renal and Exercise Rehabilitation, King's College Hospital, London, England
| | | | - Abdul Khares
- Haemodialysis Patient, c/o The Renal Association, Bristol, UK
| | - Pelagia Koufaki
- School of Health Sciences, Queen Margaret University, Edinburgh, Scotland
| | - Jeremy Levy
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, England
| | - Elizabeth Lindley
- Department of Renal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Jamie Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | - Bruno Mafrici
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | - Kay Tyerman
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enric Villar
- Lister Hospital, East & North Hertfordshire NHS Trust, Stevenage, England
| | - Martin Wilkie
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, England
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Shah S, Christianson AL, Meganathan K, Leonard AC, Schauer DP, Thakar CV. Racial Differences and Factors Associated with Pregnancy in ESKD Patients on Dialysis in the United States. J Am Soc Nephrol 2019; 30:2437-2448. [PMID: 31554657 DOI: 10.1681/asn.2019030234] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 08/23/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Pregnancy in women with ESKD undergoing dialysis is uncommon due to impaired fertility. Data on pregnancy in women on dialysis in the United States is scarce. METHODS We evaluated a retrospective cohort of 47,555 women aged 15-44 years on dialysis between January 1, 2005 and December 31, 2013 using data from the United States Renal Data System with Medicare as primary payer. We calculated pregnancy rates and identified factors associated with pregnancy. RESULTS In 47,555 women on dialysis, 2352 pregnancies were identified. Pregnancy rate was 17.8 per thousand person years (PTPY) with the highest rate in women aged 20-24 (40.9 PTPY). In the adjusted time-to-event analysis, a higher likelihood of pregnancy was seen in Native American (HR, 1.77; 95% CI, 1.33 to 2.36), Hispanic (HR, 1.51; 95% CI, 1.32 to 1.73), and black (HR, 1.33; 95% CI, 1.18 to 1.49) women than in white women. A higher rate of pregnancy was seen in women with ESKD due to malignancy (HR, 1.64; 95% CI, 1.27 to 2.12), GN (HR, 1.38; 95% CI, 1.21 to 1.58), hypertension (HR, 1.32; 95% CI, 1.16 to 1.51), and secondary GN/vasculitis (HR, 1.18; 95% CI, 1.02 to 1.37) than ESKD due to diabetes. A lower likelihood of pregnancy was seen among women on peritoneal dialysis than on hemodialysis (HR, 0.47; 95% CI, 0.41 to 0.55). CONCLUSIONS The pregnancy rate is higher in women on dialysis than previous reports indicate. A higher likelihood of pregnancy was associated with race/ethnicity, ESKD cause, and dialysis modality.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology, Kidney C.A.R.E. (Clinical Advancement, Research and Education) Program, University of Cincinnati, Cincinnati, Ohio;
| | | | | | | | - Daniel P Schauer
- Internal Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Charuhas V Thakar
- Division of Nephrology, Kidney C.A.R.E. (Clinical Advancement, Research and Education) Program, University of Cincinnati, Cincinnati, Ohio.,Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio
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Liang L, Alder M, Gorrindo P, Toledo P. Peripartum Hyperkalemia Caused by Magnesium Infusion in a Woman With End-Stage Renal Disease: A Case Report. A A Pract 2019; 13:190-192. [PMID: 31162222 DOI: 10.1213/xaa.0000000000001031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pregnancy in the setting of renal failure has higher rates of adverse events necessitating increased monitoring and treatment. Pregnant women with end-stage renal disease have higher rates of hypertension, and 50% of pregnancies are complicated by preeclampsia. We describe the case of a 32-year-old parturient with end-stage renal disease on hemodialysis with superimposed preeclampsia who developed clinically significant hyperkalemia with electrocardiographic changes after magnesium infusion. The magnesium infusion was stopped, and the patient underwent emergent hemodialysis with subsequent improvement. Hyperkalemia caused by magnesium infusion is a rare and not very well-understood phenomenon.
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Affiliation(s)
- Luke Liang
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Madeleine Alder
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Phil Gorrindo
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Paloma Toledo
- From the Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Center for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Maynard S, Guerrier G, Duffy M. Pregnancy in Women With Systemic Lupus and Lupus Nephritis. Adv Chronic Kidney Dis 2019; 26:330-337. [PMID: 31733717 DOI: 10.1053/j.ackd.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/12/2019] [Accepted: 08/19/2019] [Indexed: 11/11/2022]
Abstract
Pregnancy is an altered immunologic state in which hormonal changes impact the immune system to enable maternal tolerance of the fetus. These hormonal and immunologic changes may affect disease activity in systemic lupus erythematosus. Conversely, lupus nephritis and its complications may adversely impact pregnancy. Systemic lupus erythematosus increases the risk of pre-eclampsia and its complications, including preterm birth and intrauterine growth restriction. Comorbidities such as impaired kidney function and hypertension confer additional risk and complexity. Medications used to treat lupus nephritis may impact the fetus, so therapy needs to be tailored to balance maternal benefit and fetal risk. The diagnosis of lupus nephritis during pregnancy can be difficult, as it shares overlapping features with pre-eclampsia. Kidney biopsy is generally safe in pregnancy, and should be considered if the result will affect management. Here we review the clinical aspects of counseling, diagnosis, and management of lupus nephritis in pregnancy.
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Burgner A, Hladunewich MA. Women's Reproductive Health for the Nephrologist. Am J Kidney Dis 2019; 74:675-681. [PMID: 31221529 DOI: 10.1053/j.ajkd.2019.04.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/05/2019] [Indexed: 02/08/2023]
Abstract
Women with chronic kidney disease (CKD) are faced with complex decisions and significant challenges during their reproductive years. Contraceptive choices have a variety of side effects that can disproportionately affect women with CKD, limiting choice. CKD itself and the therapies needed to treat severe disease can affect future fertility. When conception is desired, young women with CKD must plan meticulously because an ill-timed pregnancy can result in disease progression or flare and exposure of an unborn child to potentially teratogenic medications. Among women with CKD, pregnancy risks are substantial, with up to 10-fold higher risk for preeclampsia and 6-fold higher risk for preterm delivery. These pregnancy complications associated with inadequate placentation also increase maternal and newborn risks for cardiovascular morbidity and mortality and progression to kidney failure later in life. As such, it is the obligation of every nephrologist caring for women of reproductive age to provide guidance in the choice of methods to prevent unplanned pregnancies, to choose treatments that preserve fertility, and to participate in shared decision making that optimizes pregnancy timing and outcomes. In this perspective, we review the many challenges associated with reproductive counseling in women with CKD.
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Affiliation(s)
- Anna Burgner
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, TN
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
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Mercadal L, Nizard J. Prepregnancy counselling and management of pregnancy in haemodialysis patients. Nephrol Dial Transplant 2019; 35:219-221. [DOI: 10.1093/ndt/gfz056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Lucile Mercadal
- Nephrology Department, Pitié Salpêtrière Hospital, AP-HP, Paris, France
| | - Jacky Nizard
- Hôpital Pitié Salpêtrière, Department of Obstetrics and Gynecology, Sorbonne University, Paris, France
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Piccoli GB, Cabiddu G, Gallieni M. Patients' wishes, pregnancy and vascular access: When one size does not fit all. J Vasc Access 2019; 19:518-520. [PMID: 30417759 DOI: 10.1177/1129729818809896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pregnancy in dialysis patients is a rare but important event that challenges our knowledge and demands re-thinking many aspects of our practice, including vascular access. This editorial briefly discusses some open questions on vascular access in this situation that challenge the motto 'fistula first' and underline the need for personalised approaches. Information on vascular access in pregnant women is scant. Different approaches may be considered between women on dialysis already on a well-functioning tunnelled catheter and newly placed catheters: while a tunnelled catheter in a woman already stabilised on outpatient dialysis, who has shown being able to take correct care of it and who has freely chosen this option, is a reasonable choice, central venous catheters placed during pregnancy, especially in the hospital setting, may have a high risk of complications. Conversely, pregnancy may increase the risk of development of fistula aneurysms, but the frequency of this complication is still unknown. The problem of whether or not shifting pregnant patients on peritoneal dialysis to daily haemodialysis sessions is still open, as well as the role of patients' preference for avoidance of an invasive procedure, or refuse of pain. In the wait for answers, reflecting on the problems encountered by pregnant women on dialysis should make us reflect on how to improve vascular access management for all our patients.
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Affiliation(s)
- Giorgina B Piccoli
- 1 Nephrologie Centre Hospitaler Le Mans, Le Mans, France.,2 Dipartimento di Scienze Cliniche e Biologiche Università di Torino, Torino, Italy
| | | | - Maurizio Gallieni
- 4 Nephrology and Dialysis Unit, Ospedale San Carlo Borromeo, Department of Clinical and Biomedical Sciences 'Luigi Sacco', University of Milan, Milan, Italy
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Rivera JCH, Pérez López MJ, Corzo Bermúdez CH, García Covarrubias L, Bermúdez Aceves LA, Chucuan Castillo CA, Mendoza MS, Piccoli GB, Sierra RP. Delayed Initiation of Hemodialysis in Pregnant Women with Chronic Kidney Disease: Logistical Problems Impact Clinical Outcomes. An Experience from an Emerging Country. J Clin Med 2019; 8:E475. [PMID: 30965626 PMCID: PMC6518183 DOI: 10.3390/jcm8040475] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 03/21/2019] [Accepted: 04/03/2019] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Mariana Salazar Mendoza
- Emergency Service, Hospital Regional "Lic. Adolfo López Mateos", ISSSTE, 01030 CdMx, México.
| | - Giorgina Barbara Piccoli
- Centre Hospitalier Le Mans, 72000 Le Mans, France.
- Department of Clinical and Biological Sciences, University of Torino, 10100 Torino, Italy.
| | - Ramón Paniagua Sierra
- Unidad de Investigación Médica en Enfermedades Nefrológicas, CMN Siglo XXI, 06720 CdMx, México.
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50
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Shaw J, Katopodis C, Hladunewich MA, Ryz K. Changing Dialysis Modality during Pregnancy: A Case Report. Perit Dial Int 2019; 38:456-458. [PMID: 30413638 DOI: 10.3747/pdi.2018.00054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pregnancy in patients with end-stage renal disease is rare, with a paucity of management guidelines in the literature. Various hemodialysis (HD) and peritoneal dialysis (PD) protocols have been used to successfully manage pregnancy in this population; however, there is a growing body of evidence that the best maternal and fetal outcomes are associated with intensified, high-dose HD. The optimal timing of transition from PD to HD is not known for prevalent PD patients who become pregnant. We report the case of a 32-year-old aboriginal female who became pregnant while being treated with chronic PD. She was converted to intensive HD early in the second trimester and underwent a planned caesarian section at 36 weeks with excellent outcomes for mother and child.
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Affiliation(s)
- James Shaw
- Section of Nephrology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Christina Katopodis
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Michelle A Hladunewich
- Division of Nephrology and Obstetric Medicine, Sunnybrook Health Sciences Centre, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Krista Ryz
- Section of Nephrology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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