Pregnancy In Dialysis Patients Research Articles

Segmental bioimpedance in pregnant end stage renal failure patient for dry weight titration and volume management (case report)

BackgroundVolume assessment, dry weight titration, and blood pressure control in pregnant kidney failure patients are often challenging, with physiological fluid accumulation in the trunk and lower limbs and an increased risk of preeclampsia. We used segmental bioimpedance in the volume management of our kidney failure patient on haemodialysis.Case presentationWe report a case of a female patient on maintenance haemodiafiltration with no residual kidney function for whom we used segmental bioimpedance to guide dry weight adjustment. At different gestational periods, we targeted a different extracellular to total body water ratio according to body segments. This allowed us to support her high-risk pregnancy, identify her as probably developing preeclampsia and trigger a plan for closer monitoring and delivery during the third trimester when she had rapid weight gain.ConclusionSegmental bioimpedance is a practical, simple, and non-invasive test that can be performed at the dialysis unit and is useful as an adjunct decision-making tool in the management of pregnant dialysis patients.

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

BackgroundPregnancy 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 presentationA 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.ConclusionsPregnancy 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.

Exclusion of pregnancy in dialysis patients: diagnostic performance of human chorionic gonadotropin

BackgroundA positive pregnancy test in acute or chronically ill patients has implications for the use of potentially mutagenic or teratogenic products in urgent medical therapies such as the use of chemotherapies or therapies with immunosuppressants, for anesthesia, and for time-sensitive indications like urgent surgery or organ Transplantation.Despite a lack of evidence, it is currently believed that human chorionic gonadotropin serum concentrations are always elevated in female dialysis patients even without pregnancy. It is also believed that human chorionic gonadotropin cannot be used to confirm or exclude pregnancy.MethodsHuman chorionic gonadotropin was examined in female dialysis patients (18–50 years of age), and was classified as positive above 5 mlU/ml. In addition, fertility status was determined. For an enhanced index test, the cut-off of 5 mIU/ml was used for potentially fertile patients and 14 mIU/ml for infertile patients to calculate diagnostic test accuracy. The ideal cut-off for human chorionic gonadotropin was estimated using Liu’s method with bootstrapped 95% confidence intervals. Predictors of human chorionic gonadotropin increase were analyzed using multivariable linear regression.ResultsAmong 71 women, two (2.8%) were pregnant, 46 (64.8%) potentially fertile, and 23 (32.4%) infertile. We observed human chorionic gonadotropin concentrations > 5 mIU/ml in 10 patients, which had a sensitivity of 100% (95% confidence interval: 100 to 100), a specificity of 86% (95% confidence interval: 77 to 94), a positive predictive value of 17% (95% confidence interval: 8 to 25) and a negative predictive value of 100% (95% confidence interval: 100 to 100) for the diagnosis of pregnancy. Using a cut-off > 14 mIU/ml for infertile patients or the exclusion of infertile patients increased specificity to 93% or 98%, respectively. The ideal cut-off was 25 mIU/ml (95% confidence interval: 17 to 33). Pregnancy and potential fertility, but not age, were independent predictors of human chorionic gonadotropin.ConclusionHuman chorionic gonadotropin is elevated > 5mIU/ml in 14.5% of non-pregnant dialysis patients of child-bearing age. In potentially fertile women, this cut-off can be used to exclude pregnancy. In case of an unknown fertility status, the ideal human chorionic gonadotropin cut-off was 25 mIU/ml.

Involvement of clinical engineers in outpatient maintenance dialysis up to 30 weeks of gestation in pregnant dialysis patients who wish to undergo full-term delivery

Involvement of clinical engineers in outpatient maintenance dialysis up to 30 weeks of gestation in pregnant dialysis patients who wish to undergo full-term delivery

A hemodialysis patient with bone disease after pregnancy: a case report

BackgroundPregnancy 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 presentationWe 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.ConclusionsThis case demonstrates that the combination of pregnancy and severe sHPT in dialysis patients can have deleterious consequences for bone health.

MON-058 PREGNANCY IN CHRONIC HEMODIALYSIS PATIENTS : DIAVERUM CASE REPORTS

The outcome of pregnancy in dialysis patients has long been considered to be extremely poor, and the literature concerning pregnancy while on dialysis is rather scarce. This study investigated the incidence and outcome of pregnancy in patients on chronic dialysis over the past 5 years.

Perinatal bone and calcium metabolism in the patient complicated with renal dysfunction.

The incidence of pregnancy complicated with renal dysfunction has tended to increase due to aging and progress in the treatment methods. Generally, pregnancy is allowed only in women with normal renal function and in patients with mild renal insufficiency; therefore, the incidence of osteoporosis and the resulting fragile fracture is rare during pregnancy complicated with renal dysfunction. In recent years, the incidence of pregnancy in dialysis patients and in patients who have undergone kidney transplantation has been increasing due to the progress in treatment methods. Eventually, it has become possible for patients with renal dysfunction to give birth as long as they fulfill certain conditions for pregnancy; however, the rate of preterm births has remained high. The incidence of femoral neck fracture has been about 5 times more in dialysis patients than in healthy individuals; however, the prevention and treatment of osteoporosis in pregnant dialysis patients have been difficult, since many osteoporosis medications are contraindicated in pregnant women and also their pregnancy period is not long due to the higher rate of preterm births.

Patients' wishes, pregnancy and vascular access: When one size does not fit all.

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.

Survey among nephrologists in Germany: current practice and management of pregnant women on dialysis .

To assess the experience and practice patterns of nephrologists in Germany with regard to the care of pregnant women on dialysis. The 26-item internet survey sent by email asked for demographic information, subjective proficiency, maternal and fetal complications, treatment approaches and goals. Of the 2,015 surveys sent out, 200 (10%) were available for evaluation. 38% of respondents never provided care, whereas 62% treated at least one pregnant patient on dialysis. In 306 total reported cases of pregnant women on dialysis, 58% became pregnant while on maintenance dialysis, and 42% developed dialysis-dependent renal failure in the course of pregnancy. For women on peritoneal dialysis (PD), only 22% of the nephrologists would continue PD until delivery, while 78% would convert to hemodialysis either immediately or shortly before delivery. 40% of the respondents reported complications in either mother or child. 45% of the respondents routinely provided prenatal counseling, and 2/3 of the nephrologists did not routinely perform fetal monitoring. While we found a significant difference in self-reported proficiency between nephrologists having and those not having treated pregnant women on dialysis, only 40% of all physicians felt confident in treating pregnant women on dialysis. Our survey demonstrates that the practice of nephrologists in treating pregnant women on dialysis differs significantly. These findings highlight the need for European guidelines to standardize the care of pregnant dialysis patients. .

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

BackgroundFor peritoneal dialysis patients, the likelihood of conception is low and the probability of getting through the pregnancy successfully is even lower. Almost 60 years after the first reported case of a successful pregnancy in a dialysis patient, many issues concerning pregnancy in dialysis patients remain unresolved. Our patient’s pregnancy is considered high risk as she has end stage renal failure and falls in the category of advance maternal age for pregnancy. We describe here the course of her uneventful pregnancy which we hope will contribute to the overall knowledge and management of pregnancy in elderly patients receiving peritoneal dialysis.Case presentationWe report a successful elderly multigravid pregnancy, in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD). Her pregnancy was detected early and she was closely managed by the nephrologist and obstetrician. She tolerated the same PD prescription throughout 36 weeks of pregnancy with daily ultrafiltration of 500-1500mls. Her blood pressure remained well controlled without the need of any antihypertensive medication. Her total Kt/V ranged from 1.93 to 2.73. Her blood parameters remained stable and she was electively admitted at 36 weeks for a trans-peritoneal lower segment caesarian section and bilateral tubal ligation.ConclusionsAt the age of 42, our case is the oldest reported successful pregnancy in a patient on peritoneal dialysis. With careful counselling and meticulous follow up, we have shown that woman in the early stage of end stage renal failure can successfully deliver a full term baby without any complications. Therefore, these women should not be discourage from conceiving even if they are in advanced maternal age for pregnancy.

Successful pregnancy in a South African patient with end-stage renal disease with the use of thrice-weekly nocturnal haemodialysis

Pregnancy outcomes in patients on chronic dialysis have improved as a result of the intensification of dialysis and improved perinatal care. We report the successful outcome of a pregnancy in a patient on chronic haemodialysis in Cape Town, South Africa. With intensification of her therapy using thrice-weekly, nocturnal haemodialysis the pregnancy was maintained until 34 weeks at which time a 1.86 kg baby boy was delivered by elective caesarean section. One year later the patient was doing well on maintenance haemodialysis and the baby was achieving his developmental milestones. This report highlights our ability to employ a multi-disciplinary approach and prolonged, nocturnal haemodialysis to support pregnant dialysis patients in the South African setting and achieve good outcomes for both mother and baby.

Pregnancy in dialysis patients in the new millennium: a systematic review and meta-regression analysis correlating dialysis schedules and pregnancy outcomes.

Advances have been made in the management of pregnancies in women receiving dialysis; however, single-centre studies and small numbers of cases have so far precluded a clear definition of the relationship between dialysis schedules and pregnancy outcomes. The aim of the present systematic review was to analyse the relationship between dialysis schedule and pregnancy outcomes in pregnancies in chronic dialysis in the new millennium. Medline-PubMed, Embase and the Cochrane library were searched (1 January 2000-31 December 2014: MESH, Emtree, free terms on pregnancy and dialysis). A separate analysis was performed for case series (more than five cases) and case reports. Meta-regression was performed in case series dealing with the larger subset of haemodialysis (HD) patients; case reports were analysed separately [according to peritoneal dialysis (PD) versus HD; conception before or during dialysis]. We obtained 190 full texts and 25 congress abstracts from 2048 references. We selected 101 full papers and 25 abstracts (36 series; 90 case reports), for a total of 681 pregnancies in 647 patients. In the case series (574 pregnancies in 543 patients), preterm delivery was extremely frequent (83%). Meta-regression analysis showed a relationship between hours of dialysis per week in HD and preterm delivery, and was significant for preterm deliveries (<37 gestational weeks: P = 0.044; r2 = 0.22) and for small for gestational age (SGA) (P = 0.017; r2 = 0.54). SGA was closely associated with the number of dialysis sessions per week (P = 0.003; r2 = 0.84). Case report analysis suggests a lower incidence of SGA on HD versus PD (31 versus 66.7%; P = 0.015). No evidence of an increased risk of congenital abnormality was found in the retrieved papers. Data on pregnancy on dialysis are heterogeneous but rapidly accumulating; the main determinant of outcomes on HD is the dialysis schedule. The differences between PD and HD should be further analysed.

Repeated Pregnancy with Delivery of Full Term Baby in a Dialysis Woman: Case Report and Review of Literature

Pregnancy is a rare event in a woman on maintenance dialysis. We report a case of 40 year old patient on hemodialysis who had 2 uncomplicated pregnancy 6 years apart with delivery of full term healthy babies. The fertility and conception in patients with renal failure is reviewed. The reported pregnancies and their outcome from different countries in patients on dialysis showed that majority result in abortion, still birth or preterm babies. The care of a pregnant dialysis patient should involve increased dialysis hours and special care to dialysis bath and heparin use. The care should involve team work of nephrologists, obstetricians, and nutritionists and well trained nursing staff.

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.

Intensive Hemodialysis Associates with Improved Pregnancy Outcomes

Pregnancy is rare in women with ESRD and when it occurs, it is often accompanied by significant maternal and fetal morbidity and even mortality. Preliminary data from the Toronto Nocturnal Hemodialysis Program suggested that increased clearance of uremic toxins by intensified hemodialysis improves pregnancy outcomes, but small numbers and the absence of a comparator group limited widespread applicability of these findings. We compared pregnancy outcomes from 22 pregnancies in the Toronto Pregnancy and Kidney Disease Clinic and Registry (2000-2013) with outcomes from 70 pregnancies in the American Registry for Pregnancy in Dialysis Patients (1990-2011). The primary outcome was the live birth rate and secondary outcomes included gestational age and birth weight. The live birth rate in the Canadian cohort (86.4%) was significantly higher than the rate in the American cohort (61.4%; P=0.03). Among patients with established ESRD, the median duration of pregnancy in the more intensively dialyzed Toronto cohort was 36 weeks (interquartile range, 32-37) compared with 27 weeks (interquartile range, 21-35) in the American cohort (P=0.002). Furthermore, a dose response between dialysis intensity and pregnancy outcomes emerged, with live birth rates of 48% in women dialyzed ≤20 hours per week and 85% in women dialyzed >36 hours per week (P=0.02), with a longer gestational age and greater infant birth weight for women dialyzed more intensively. Pregnancy complications were few and manageable. We conclude that pregnancy may be safe and feasible in women with ESRD receiving intensive hemodialysis.

Successful pregnancy in a 31-year-old peritoneal dialysis patient with bilateral nephrectomy.

Frequency of pregnancy among childbearing age women with end-stage renal disease (ESRD) undergoing long-term periodic dialysis ranges from 1% to 7%. Although pregnancy in dialysis women with ESRD is considered a largely high-risk pregnancy, occurrence of successful pregnancy is not impossible with success rates approaching 70%. Rates of successful pregnancy are greatly impacted by early pregnancy diagnosis and preserved residual renal functions. Herein, to the best of our knowledge, we report the first case of successful pregnancy (despite late diagnosis at 14 weeks of gestation) in a 31-year-old peritoneal dialysis patient with bilateral nephrectomy and no whatsoever preserved residual renal function. Moreover, a literature review on pregnancy in dialysis patients is presented.

Beta HCG levels in a pregnant dialysis patient: a cautionary tale

Conception is rare in patients on chronic dialysis and diagnosis is often delayed as it is least expected. Serum beta HCG levels are elevated in both pregnant and non-pregnant dialysis patients, and pregnant dialysis patients have slightly higher beta HCG levels when compared with normal pregnancy. This can be erroneously interpreted as non-viable pregnancy and so results should be viewed with caution. Serial beta HCG levels must be followed when non-viable pregnancy is suspected in a dialysis patient before contemplating termination of pregnancy as described in our case.

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

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

Pregnancy in Dialysis Patients

Although successful pregnancy is rare, results attained with higher dialysis efficiency and the spread of dialysis to different cultural and religious settings are changing the panorama. In this study, we systematically review the recent literature (2000 through 2008) on pregnancy in dialysis. Medline on OVID was searched in November 2008, with MESH and free terms on pregnancy and chronic kidney disease or dialysis; limits were human subjects and English-language articles. Case reports were excluded to minimize publication bias. The final selection and extraction of data were performed in duplicate. From 2840 references, 241 full-text articles were retrieved; eight fulfilled the selection criteria, and two were added from reference lists. In the 10 studies (nine of 10 monocentric), 90 pregnancies were observed in 78 patients (range of cases five to 15). The studies were heterogeneous for definition of outcomes, duration (2 to 16 yr), period (1988 through 1998 to 2000 through 2006), age (25 to 35 yr), and support and dialysis therapy. Daily dialysis was frequently used; type of treatment, membranes, and flows varied widely. Hypertension and anemia were frequent concerns for the mothers. Intrauterine deaths, hydramnios, and small-for-gestational-age or preterm infants were frequent. The possibility of a healthy offspring ranged from 50 to 100% (overall 76.25%). Evidence on pregnancy in dialysis is heterogeneous; however, the growing number of reports worldwide and the improving results suggest that we should reconsider our counseling policy, which only rarely includes pregnancy in dialysis patients.

Pregnancy in dialysis patients: Two successful cases from a saudi renal center and management guidelines

Fertility is markedly reduced in potients with chronic renal failure. Wi here by repord two cases of seccuessful prengnancy in 2 Saudi patienst, the first with chronic renal failure on chronic hemodialysis and the second with pre-existing renal disease aggravated by pregnancy.