Dialysis on Pregnancy: An Overview

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

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Patient Outcome in Pregnancy Requiring Dialysis: A Case Series

The optimal management of pregnant dialysis patients remains a great challenge for nephrologists, end-stage renal disease being a predictor of adverse outcomes in this condition. We report a single-center experience of four patients requiring dialysis during pregnancy, all of which resulted in successful delivery of viable infants. Our success rate may reflect an overall improvement in management of this population, with special attention paid to multiple risk factors. These include blood pressure and volume control, anemia management with erythropoietin analogues, nutritional intake and total dose of dialysis.

Pregnancy and renal outcomes in lupus nephritis: an update and guide to management

Systemic lupus erythematosis (SLE) commonly affects women of child bearing-age, and advances in treatment have resulted in an increasing number of women with renal involvement becoming pregnant. Knowledge of the relationship of the condition with respect to fertility and pregnancy is important for all clinicians involved in the care of women with lupus nephritis because they have complicated pregnancies. Presentation of lupus nephritis can range from mild asymptomatic proteinuria to rapidly progressive renal failure and may occur before, during, or after pregnancy. The timing of diagnosis may influence pregnancy outcome. Pregnancy may also affect the course of lupus nephritis. All pregnancies in women with lupus nephritis should be planned, preferably after more than six-months of quiescent disease. Predictors of poor obstetric outcome include active disease at conception or early pregnancy, baseline poor renal function with Creatinine >100 μmol/L, proteinuria >0.5 g/24 hours, presence of concurrent antiphospholipid syndrome and hypertension. In this review the most recent studies of pregnancies in women with lupus nephritis are discussed and a practical approach to managing women prepregnancy, during pregnancy and post-partum is described.

Pregnancy in Patients with Chronic Renal Insufficiency at Hospital de Clínicas of Porto Alegre, Brazil

Chronic renal insufficiency (CRI) decreases reproductive capability. The biggest challenge in monitoring pregnant women with renal disease is to keep the intrauterine environment favorable to the fetus. One of the common prognosis in this kind of pregnancy involves premature birth, restricted growth and mental retardation. Also, the risk of developing complications is higher for the mother. This study focuses on evaluating CRI patients' clinical conditions during pregnancy, checking fetal development and birth and verifying the prevalence of CRI in pregnant women attended at Hospital de Clínicas of Porto Alegre-Brazil (HCPA). This is a retrospective study with both a control and an case group of pregnant women with CRI who delivered their babies at HCPA from 1989 to 1999. The case group is composed of pregnant women with CRI, while the control group was paired according to maternal and gestational ages and to the time of the delivery, which should be the same both in the experimental and in the control group. Among the criteria usually used to identify CRI, we chose the creatinine level higher than 1.5 mg/dL. Significance was established in 0.05%. Our results demonstrate that the prevalence of CRI was 6/10,000 births. Average maternal age was 28. Sixty five per cent of the patients, in both the groups, underwent prenatal monitoring, 40% presented preeclampsia, 48% presented urinary infection. Among the CRI complications, 48% of the cases presented anemia and 56% presented systemic hypertension. Average hematocrit was 24% while hemoglobin was 6.7 g/dL, which leads us to the conclusion that patients presented anemia during pregnancy. Average creatinine was 4.61 mg/dL. It is relevant that 64% of the CRI cases migrated to a substitutive renal therapy method. As for the fetus evolution in the case group, we confirmed the findings of previous studies, such as larger number of premature births (newborns younger than 36 weeks in 60% of the cases), larger number of cesarean section (56%), lower weight at birth (1980 gr. in average), lower APGAR scores in the first and fifth minute (4.13 and 5.08, respectively) in comparison to the control group (7.52 and 8.63, respectively). We can state that babies born from CRI patients present underdevelopment. Also, mothers with CRI develop more complications during pregnancy.

Management of the pregnant chronic dialysis patient

Although unusual, pregnancy in chronic dialysis patients does occur. In fact, the percent of successful pregnancies in women on chronic dialysis may be increasing. But unfortunately, the rates for premature delivery, neonatal death, maternal hypertension, and preeclampsia in the chronic pregnant dialysis patient are high. Consequently, to have a successful outcome for the pregnant dialysis patient, close collaboration between the patient, her nephrologists, high-risk obstetrician, neonatalogist, dialysis nurse, and nutritionist is required. This article reviews and discusses the need for meticulous attention to anemia management, blood pressure control, fluid status, hemodialysis, and peritoneal dialysis prescription, nutrition, and fetal monitoring in the pregnant chronic dialysis patient.

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

A case of pregnancy in a 27-year-old woman on peritoneal dialysis is presented. The case report is a detailed description of her course including changes in her peritoneal dialysis regimen and the use of continuous cycling to maximize dialysis adequacy while addressing the patient's recurrent abdominal pain and fullness. Also described is the management of complications including hypertension, gestational diabetes, and premature rupture of membranes. The discussion reviews the diagnosis of pregnancy, factors that may relate to outcome, and a detailed comparison of pregnancy outcomes in patients on dialysis to the general population.

Puberty in chronic renal failure

Puberty is a period of transition characterized by a sequence of profound physical and psychological changes leading to full sexual maturity. This process is driven and orchestrated by the awakening of the gonadotropic hormone axis. Chronic renal failure and its treatment may interfere with the onset and progress of puberty by numerous mechanisms including endocrine, metabolic and neuropsychological abnormalities, and drug effects. On average, the onset of puberty is delayed by 2 years in children with chronic renal failure, even after successful transplantation. Moreover, pubertal height gain is only 50% of that observed in healthy children. In this report, we discuss the endocrine mechanisms underlying these alterations and highlight new therapeutical options for pubertal growth failure.