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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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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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Wiles K, de Oliveira L. Dialysis in pregnancy. Best Pract Res Clin Obstet Gynaecol 2018; 57:33-46. [PMID: 30606688 DOI: 10.1016/j.bpobgyn.2018.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 11/15/2018] [Accepted: 11/22/2018] [Indexed: 12/27/2022]
Abstract
Although kidney disease impacts on fertility, increasing numbers of pregnancies are reported in women on dialysis. Despite a trend of increasing live birth rates over recent decades, pregnancies on dialysis remain high risk with increased rates of adverse pregnancy outcomes including pregnancy loss, pre-eclampsia, pre-term delivery, low birth weight and higher levels of neonatal care. This article describes the prevalence of dialysis and pregnancy in women of childbearing age, with relevant information regarding the effects of end-stage renal disease on fertility in women. Pregnancy outcomes for women on dialysis are summarised, including their association with dialysis intensity. A guide to pre-pregnancy counselling, and the management of pregnancy on dialysis is provided. Factors that inform the decision to commence dialysis in pregnancy are examined. The advantages and disadvantages of peritoneal dialysis in pregnancy are discussed.
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Affiliation(s)
- Kate Wiles
- Department of Women and Children's Health, King's College London and the Biomedical Research Centre, Guy's and St. Thomas' NHS Foundation Trust, London SE1 7EH, United Kingdom.
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Abstract
Pregnancy is uncommon in women with end-stage renal disease (ESRD). Fertility rates are low in women on dialysis, and physicians still frequently counsel women with ESRD against pregnancy. Advancements in the delivery of dialysis and obstetric care have led to improved live birth rates in women on dialysis, so pregnancy for young women with ESRD is now more feasible and safer. However, these pregnancies remain high-risk for both maternal and fetal complications, necessitating experienced multidisciplinary care. In this article, we review fertility issues in women with ESRD, discuss pregnancy outcomes in women on dialysis, and provide an approach for management of pregnant women with ESRD.
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Affiliation(s)
- Jessica Tangren
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Molly Nadel
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Malin GL, Wallace S, Hall M, Ferraro A. Peritoneal dialysis throughout pregnancy with successful outcome: A case report. Obstet Med 2017; 11:98-100. [PMID: 29997695 DOI: 10.1177/1753495x17737002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 09/07/2017] [Indexed: 11/16/2022] Open
Abstract
We present the case of a 28-year-old woman who was para 1, with end-stage renal failure secondary to reflux nephritis. She conceived after two years on peritoneal dialysis. She successfully continued this throughout pregnancy, although her antenatal course was complicated by an episode of peritonitis. Induction at 34 weeks resulted in a vaginal birth of a live boy. Her postnatal course was uncomplicated. We reviewed the literature regarding peritoneal dialysis in pregnancy. A recent systematic review identified 14 cases. When the outcomes of these women were compared with those receiving haemodialysis in pregnancy, there was a significantly higher proportion of small for gestational age fetuses, but other parameters were comparable. Two cases of peritonitis complicating peritoneal dialysis in pregnancy have been reported, both successfully treated. We conclude that peritoneal dialysis may be continued in pregnancy with successful maternal and fetal outcome, particularly in women with some residual renal function.
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Affiliation(s)
- G L Malin
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Svf Wallace
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - M Hall
- Nottingham Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - A Ferraro
- Nottingham Renal and Transplant Unit, Nottingham University Hospitals NHS Trust, Nottingham, UK
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Piccoli GB, Minelli F, Versino E, Cabiddu G, Attini R, Vigotti FN, Rolfo A, Giuffrida D, Colombi N, Pani A, Todros T. Pregnancy in dialysis patients in the new millennium: a systematic review and meta-regression analysis correlating dialysis schedules and pregnancy outcomes. Nephrol Dial Transplant 2016; 31:1915-1934. [DOI: 10.1093/ndt/gfv395] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Fitzpatrick A, Mohammadi F, Jesudason S. Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby. Int J Womens Health 2016; 8:273-85. [PMID: 27471410 PMCID: PMC4948734 DOI: 10.2147/ijwh.s76819] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Parenthood is a central focus for women with chronic kidney disease, but raises important fears and uncertainties about risks to their own and their baby’s health. Pregnancy in women with background kidney disease, women receiving dialysis, or those with a functioning kidney transplant poses a challenging clinical scenario, associated with high maternal–fetal morbidity and potential impact on maternal renal health. Improvements in care over recent decades have led to a paradigm shift with cautious optimism and growing interest regarding pregnancies in women with chronic kidney disease. In this review, we discuss obstetric and renal outcomes, and practical aspects of management of pregnancy in this complex cohort.
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Affiliation(s)
| | - Fadak Mohammadi
- Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital
| | - Shilpanjali Jesudason
- Women's and Babies Division, Women's and Children's Hospital; Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital; Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
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Abstract
PURPOSE OF REVIEW This article reviews the available literature about the incidence, outcomes, and the management of pregnancy in women with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) who require renal replacement therapy. RECENT FINDINGS Pregnancy in women with advanced CKD and ESRD can result in serious adverse maternal and fetal outcomes, but improved outcomes have been noted in recent years, likely secondary to intensified dialysis regimens. More intensive dialysis allows for the gentle removal of water, solutes, and uremic toxins, which theoretically results in near-normal maternal renal physiology, an improvement in placental blood flow, and therefore a better environment for fetal growth and development. As management remains complex, a close joint collaboration between the high-risk obstetrical team and nephrology is essential. SUMMARY Pregnancy on dialysis is becoming a viable option for women with advanced CKD and ESRD who do not have immediate access to transplantation.
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Cabiddu G, Castellino S, Gernone G, Santoro D, Giacchino F, Credendino O, Daidone G, Gregorini G, Moroni G, Attini R, Minelli F, Manisco G, Todros T, Piccoli GB. Best practices on pregnancy on dialysis: the Italian Study Group on Kidney and Pregnancy. J Nephrol 2015; 28:279-88. [PMID: 25966799 DOI: 10.1007/s40620-015-0191-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 03/06/2015] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pregnancy during dialysis is increasingly being reported and represents a debated point in Nephrology. The small number of cases available in the literature makes evidence-based counselling difficult, also given the cultural sensitivity of this issue. Hence, the need for position statements to highlight the state of the art and propose the unresolved issues for general discussion. METHODS A systematic analysis of the literature (MESH, Emtree and free terms on pregnancy and dialysis) was conducted and expert opinions examined (Study Group on Kidney and Pregnancy; experts involved in the management of pregnancy in dialysis in Italy 2000-2013). Questions regarded: timing of dialysis start in pregnancy; mode of treatment, i.e. peritoneal dialysis (PD) versus haemodialysis (HD); treatment schedules (for both modes); obstetric surveillance; main support therapies (anaemia, calcium-phosphate parathormone; acidosis); counselling tips. MAIN RESULTS Timing of dialysis start is not clear, considering also the different support therapies; successful pregnancy is possible in both PD and HD; high efficiency and strict integration with residual kidney function are pivotal in both treatments, the blood urea nitrogen test being perhaps a useful marker in this context. To date, long-hour HD has provided the best results. Strict, personalized obstetric surveillance is warranted; therapies should be aimed at avoiding vitamin B12, folate and iron deficits, and at correcting anaemia; vitamin D and calcium administration is safe and recommended. Women on dialysis should be advised that pregnancy is possible, albeit rare, with both types of dialysis treatment, and that a success rate of over 75% may be achieved. High dialysis efficiency and frequent controls are needed to optimize outcomes.
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Groothoff J. Pregnancy during dialysis: still a challenge to get there, but worth the effort. Nephrol Dial Transplant 2015; 30:1053-5. [PMID: 25934990 DOI: 10.1093/ndt/gfv124] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 03/31/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jaap Groothoff
- Paediatric Nephrology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, the Netherlands
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Panaye M, Jolivot A, Lemoine S, Guebre-Egziabher F, Doret M, Morelon E, Juillard L. [Pregnancies in hemodialysis and in patients with end-stage chronic kidney disease : epidemiology, management and prognosis]. Nephrol Ther 2014; 10:485-91. [PMID: 25457994 DOI: 10.1016/j.nephro.2014.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 06/07/2014] [Accepted: 06/25/2014] [Indexed: 10/24/2022]
Abstract
Pregnancy in patients presenting end-stage renal disease is rare and there are currently no recommendations for the management of these patients. In hemodialysis patients, reduced fertility and medical reluctance limit the frequency of pregnancies. Although the prognosis has significantly improved, a significant risk for unfavorable maternal (pre-eclampsia, eclampsia) and fetal (pre-term birth, intrauterine growth restriction, still death) outcome still remains. Increasing dialysis dose with the initiation of daily dialysis sessions, early adaptation of medications to limit teratogenicity and management of chronic kidney disease complications (anemia, hypertension) are required. A tight coordination between nephrologists and obstetricians remains the central pillar of the care. In peritoneal dialysis, pregnancy is also possible with modification of the exchange protocol and reducing volumes.
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Affiliation(s)
- Marine Panaye
- Service de néphrologie, hôpital Édouard-Herriot, pavillon P, 5, place d'Arsonval, 69003 Lyon, France.
| | - Anne Jolivot
- Service de néphrologie, hôpital Édouard-Herriot, pavillon P, 5, place d'Arsonval, 69003 Lyon, France
| | - Sandrine Lemoine
- Service de néphrologie, hôpital Édouard-Herriot, pavillon P, 5, place d'Arsonval, 69003 Lyon, France; Université Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France
| | - Fitsum Guebre-Egziabher
- Service de néphrologie, hôpital Édouard-Herriot, pavillon P, 5, place d'Arsonval, 69003 Lyon, France
| | - Muriel Doret
- Université Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France; Service gynécologie obstétrique, hôpital Femme-Mère-Enfant, 59, boulevard Pinel, 69500 Bron, France
| | - Emmanuel Morelon
- Université Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France; Service transplantation et immunologie clinique, hôpital Édouard-Herriot, pavillon P, 5, place d'Arsonval, 69003 Lyon, France
| | - Laurent Juillard
- Service de néphrologie, hôpital Édouard-Herriot, pavillon P, 5, place d'Arsonval, 69003 Lyon, France; Université Lyon 1, 43, boulevard du 11-Novembre-1918, 69100 Villeurbanne, France
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12
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Batarse RR, Steiger RM, Guest S. Peritoneal dialysis prescription during the third trimester of pregnancy. Perit Dial Int 2014; 35:128-34. [PMID: 24711639 DOI: 10.3747/pdi.2013.00229] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 01/04/2014] [Indexed: 11/15/2022] Open
Abstract
Management of the pregnant patient on peritoneal dialysis (PD) is potentially challenging because uterine enlargement may negatively affect catheter function and prescribed dwell volumes. Additional reports of the management of these patients are needed. Here, we describe a near-full-term delivery in a 27-year-old woman who had been on dialysis for 7 years. Peritoneal dialysis was continued during the entire pregnancy. In the third trimester, a higher delivered automated PD volume allowed for adequate clearance and control of volume status. A decision to hospitalize the patient to limit activity and facilitate the delivery of increased dialysate is believed to have contributed to the successful outcome for mother and infant. Our report discusses the management of this patient and reviews published dialysis prescriptions used during the third trimester of pregnancy in patients treated with PD.
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Affiliation(s)
- Rodolfo R Batarse
- Nephrology, Hypertension, Transplant Medicine, Rancho Mirage, and University of California San Diego Medical Center, San Diego, California, USA
| | - Ralph M Steiger
- Desert Regional Medical Center, Palm Springs, California, USA
| | - Steven Guest
- Baxter Healthcare Corporation, Deerfield, Illinois, USA
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Dialysis and pregnancy in end stage kidney disease associated with lupus nephritis. Case Rep Med 2013; 2013:923581. [PMID: 24348579 PMCID: PMC3854106 DOI: 10.1155/2013/923581] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 09/24/2013] [Indexed: 11/18/2022] Open
Abstract
Female patients with systemic lupus erythematosus are often of childbearing age at diagnosis, and though fertility in these patients is similar to the general population, successful pregnancy remains a rare occurrence. This incidence is, however, increasing and the management of these high risk pregnancies is often further complicated by the patient's need for dialysis as a result of lupus nephritis (LN). We share our experience in managing two LN patients with successful pregnancies, one on automated peritoneal dialysis and the other on haemodialysis, as well as a review of cases in the literature.
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Jesudason S, Grace BS, McDonald SP. Pregnancy outcomes according to dialysis commencing before or after conception in women with ESRD. Clin J Am Soc Nephrol 2013; 9:143-9. [PMID: 24235285 DOI: 10.2215/cjn.03560413] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND OBJECTIVES Pregnancy in ESRD is rare and poses substantial risk for mother and baby. This study describes a large series of pregnancies in women undergoing long-term dialysis treatment and reviews maternal and fetal outcomes. Specifically, women who had conceived before and after starting long-term dialysis are compared. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENT All pregnancies reported to the Australian and New Zealand Dialysis and Transplantation Registry from 2001 to 2011 (n=77), following the introduction of specific parenthood data collection, were analyzed. RESULTS Between 2001 and 2011, there were 77 pregnancies among 73 women. Of these, 53 pregnancies were in women who conceived after long-term dialysis was established and 24 pregnancies occurred before dialysis began. The overall live birth rate (after exclusion of elective terminations) was 73%. In pregnancies reaching 20 weeks gestation, the live birth rate was 82%. Women who conceived before dialysis commenced had significantly higher live birth rates (91% versus 63%; P=0.03), but infants had similar birthweight and gestational age. This difference in live birth rate was primarily due to higher rates of early pregnancy loss before 20 weeks in women who conceived after dialysis was established. In pregnancies that reached 20 weeks or more, the live birth rate was higher in women with conception before dialysis commenced (91% versus 76%; P=0.28). Overall, the median gestational age was 33.8 weeks (interquartile range, 30.6-37.6 weeks) and median birthweight was 1750 g (interquartile range, 1130-2417 g). More than 40% of pregnancies reached >34 weeks' gestation; prematurity at <28 weeks was 11.4% and 28-day neonatal survival rate was 98%. CONCLUSIONS Women with kidney disease who start long-term dialysis after conception have superior live birth rates compared with those already established on dialysis at the time of conception, although these pregnancies remain high risk.
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Affiliation(s)
- Shilpanjali Jesudason
- Central and Northern Adelaide Renal and Transplantation Service and, †Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia, ‡Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Abstract
Kidney disease and pregnancy may exist in two general settings: acute kidney injury that develops during pregnancy, and chronic kidney disease that predates conception. In the first trimester of pregnancy, acute kidney injury is most often the result of hyperemesis gravidarum, ectopic pregnancy, or miscarriage. In the second and third trimesters, the common causes of acute kidney injury are severe preeclampsia, hemolysis-elevated liver enzymes-low platelets syndrome, acute fatty liver of pregnancy, and thrombotic microangiopathies, which may pose diagnostic challenges to the clinician. Cortical necrosis and obstructive uropathy are other conditions that may lead to acute kidney injury in these trimesters. Early recognition of these disorders is essential to timely treatment that can improve both maternal and fetal outcomes. In women with preexisting kidney disease, pregnancy-related outcomes depend upon the degree of renal impairment, the amount of proteinuria, and the severity of hypertension. Neonatal and maternal outcomes in pregnancies among renal transplant patients are generally good if the mother has normal baseline allograft function. Common renally active drugs and immunosuppressant medications must be prescribed, with special considerations in pregnant patients.
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Abstract
The ovulatory menstrual cycle is known to be affected on multiple levels in women with advanced renal disease. Menstrual irregularities, sexual dysfunction, and infertility worsen in parallel with the renal disease. Pregnancy in women with ESRD on dialysis is therefore uncommon. Furthermore, when pregnancy does occur, it can prove hazardous to both mother and baby owing to a multitude of potential complications including accelerated hypertension and preeclampsia, poor fetal growth, anemia, and polyhydramnios. Data are emerging, however, to suggest that pregnancy while on intensified renal replacement regimens may result in better pregnancy outcomes, and emerging trends include the decreased rate of therapeutic abortions probably reflecting a change in counseling practices over time. Nevertheless, a pregnant woman on intensive dialysis requires meticulous follow-up by a dedicated team including nephrology, obstetrics, and a full multidisciplinary staff. In this article, we will address fertility issues in young women with ESRD, review pregnancy outcomes in women on both hemodialysis and peritoneal dialysis, and provide suggestions for the management of the pregnant women on intensive hemodialysis.
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Affiliation(s)
- Michelle Hladunewich
- Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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