Renal Failure and Dialysis in

Pregnancy
David Shure

Differential Diagnosis
1.

2.

3.

4.

FSGS Pro: HTN, non-remitting, albumin close to NL

Con: expected creatinine to be higher after several years
Membranous Nephropathy Pro: wax/waning course
Con: often with lower albumin, edema
Diabetic Nephropathy Pro: proteinuria, time course
Con:poor evidence for DM
FMD - Pro: unequal sized kidneys, young female, HTN
hx, renal arteries not commented on in US

Nephrology Consult
1. Is there any indication and/ or benefit to the
fetus if we begin HD at this time?
2. Can we preserve any residual maternal renal
function?

OB team trying to prolong in-utero growth/

length of pregnancy, not sure if pt is masking
severe preeclampsia

Why did Ob Deliver the Baby?

7/21 pt c/o HA, and 7/23 severe RUQ
tenderness and epigastric pain, decision made
to deliver fetus based on:
Severe superimposed Preeclampsia in setting of
chronic HTN
Also, mild thrombocytopenic further led to
diagnosis of severe preeclampsia

Normal Physiologic Alterations

of Pregnancy

Normal Renal Alterations

in Pregnancy

Changes in GFR
GFR and RBF rise markedly
Glomerular hyperfiltration results in normal
reduction in the plasma creatinine concentration
to about 0.4 to 0.5 mg/dL
Blood urea nitrogen (BUN) and uric acid levels
fall for the same reason

Effects of Pregnancy
on Renal Disease
1.
2.
3.
4.

cases proteinuria worsen

cases HTN develops
Worsening edema if nephrotic
0-10% women with NL or mild reduction in
GFR have permanent decline in renal function

Views on Pregnancy and Dialysis

Children of women with renal disease used to
be born dangerously or not at all - not at all if
their doctors had their way, Lancet, 1975
Show me a method of birth control more
effective than end stage renal disease, Roger
Rodby MD, 1991
Even if a woman on CAPD ovulates, doesnt the
egg just float away?, Rodby, 1992

Why dont uremic women

get pregnant?

Most beyond child bearing age

Libido/ frequency of intercourse reduced
Dont ovulate
Absence of increase in basal body temperature
during the luteal phase of cycle
Elevated circulating prolactin concentrations
Elevated PRL impairs hypothalamic-pit function

Actually, they do get pregnant!

1st successful term pregnancy in 35 y/o dialysed
pt in 1971, Confortini, et al.
Yr 2000: >15,000 women of childbearing age
getting dialysis
For every person w/CKD 5, 20 have CKD 3 or 4
w/GFR <60, suggesting ~300,000 women
w/CKD potentially able to bear children

Course of Renal Disease in

Pregnancy
Baseline azotemia = more rapid deterioration
As renal dz progresses, ability to maintain nl
pregnancy deteriorates, and presence of HTN
incr likelihood of renal deterioration
Renal dysfunction - greater risk for
complications incl preeclapsia, premature
delivery, IUGR

Pregancy during dialysis: case report and

management guidelines; Giatras, et al. 1998

32 y/o AA woman, G4, P2, A1

FSGS and chronic interstitial nephritis
Renal/obstetric protocol implemented
Increased HD to 4 hrs/ 4 sessions/ week
maintain prediaysis BUN <50
At each HD session, blood flow gradually
increased over 1st 30 minutes of HD, from 180
to 300 ml/min
Kt/V 1.02 - 1.66

Giatras Protocol
Dialysis performed in left lateral decubitus
position
Est maternal dry wt incrased by 500 g every 10d
EPO administered at each HD session, to
maintain HCT 32-34%
Vit D, folic acid and MVI admin
Evid of malnutrition prior to pregnancy, so
3000kcal/day diet w>100g protein/ day

Obstetric Surveillance

From 25 wks gestation

Serial BP
Uterine and umbilical artery perfusion evaluation
Cont fetal heart rate tracing before, during and
after HD
There were no signif changes in uterine or
umbilical artery S/D ratios at any time of HD, and
no sig alteration in maternal MAP during HD
Pt delivered at 32 wks gestation, due to PROM

Common Themes in Dialysing

Pregnant Patients
1. Keeping BUN < 50
2. Increasing dialysis time and frequency
3. BP control
4. Managing anemia with increasing doses of ESA
5. Fetal monitoring once viability reached

BUN <50 Hypothesis?

1963 150 women varying degrees of CKD, none
on dialysis, found the single most important
factor influencing fetal outcome was BUN
Fetal mortality directly proportional to BUN
Hypothesis: intensive dialysis in pregnant
women w/renal dz might improve fetal outcomes

Increasing frequency and

time on dialysis?
May be beneficial in reducing incidence of
polyhydramnios by reducing urea and water load
Less dialysis-induced hypotension
More liberal diet

Pregnancy and Dialysis

Bagon, et al. 1998 Belgium
American Jrnl Kid Diseases
Spurred by the report of 5 pregnancies in 5 pts
on chronic HD in 2 dialysis units bet 1989-1996
1st national survey of its kind which revealed a
total of 15 pregnancies in HD - all dialysis
centers in Belgium questioned for pts bet 19751996

Study Population Figures

32 Belgian HD Centers - Nationwide

4,135 pts on HD
Jan 1, 1975 and Dec 31, 1996, 17,618 pts
7,982 female
Among female pts, 1,472 were of childbearing
years (18-44)
In addition to the 5 pts identified in the authors
clinics, 10 others identified.
All preterm, all w/low birth rate, 3 intrauterine
deaths, 3 neonatal deaths; 9 survived.

Characteristics of Personal Cases

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Pt #12: initially treated in a ctr in which

target Hb levels were lower than 10-12

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Pt #13, s/p parathyroidectomy just

before conception

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Pt #14

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5 Highlighted Cases Are Those

Started on HD after Pregnancy

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Case Characteristics/ Outcomes

4/5 cases survived, 1 in-utero death

All deliveries preterm
All w/ low birth wt (<2500 gm)
No congenital malformations
Polyhydramnios very common
Most cases received steroids for FLM
Case 15 hospitalized for severe HTN, and IUGR,
creat clear 18 ml/ min, at 29 wks fetus w/severe
acidosis, bradycardia and death

Dialysis Dosing
15 pregnancies went beyond 1st trimester
Frequency of HD was increased immediately or
progressively to 16 to 24 hrs
No difference bet successful pregnancies and
failed ones for # mths on HD prior to conception
or age at conception.
For successful pregnancies + correlation bet
birth wt and excess dialysis hrs delivered over
entire pregnancy.

Success Rate
80% (4/5) when HD initiated after onset of
pregnancy (pregnancy first)
50% (5/10) when HD was the first event
Pregnancy first cases have a significant
residual renal function and even may benefit
from preventive dialysis, to be taken on dialysis
at a stage of renal failure that would not justify
dialysis in the eyes of many were it not for the
very special setting of a pregnant state

Obstetrical Problems
Main Problem: premature births
In this study 3 died due to severe prematurity
Polyhydramnios present in almost all cases,
may be cause of preterm labor
Growth retarded babies at highest risk for
intrauterine death
Maternal prognosis is good

Should we Initiate Dialysis in Pts

w/Low Cr Clearance?
Hou, S., Pregnancy in Women on Hemodialysis,
1994, revealed better outcomes of pregnancy in
women w/ significant residual renal function or
who initiate pregnancy before they need dialysis.
May reduce incidence of polyhydramnios, lower
urea and lowers water load, also reducing risk of
dialysis-induced hypotension

Registry of Pregnancy
in Dialysis Patients
Okundaye, I., Abrinko, P., Hou S., 1998
Am Jrnl Kid Ds
Questionnaires to 2,299 dialysis centers in US
Women 14-44 yrs
Pregnancies bet 1992 and 1995 were evaluated

Registry includes ~ 48% of women of

childbearing years receiving HD in US 1992-1995

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USRDS
In 1992: 12,992 women under age 44 receiving
dialysis in US
This registry covers approx 48% of women of
childbearing age receiving dialysis in US

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Women who conceived after start dialysis, 40.2%

infants survived, c/w 73.6% in women who
started dial after conception (p<.001)

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Frequency of Prematurity and Low Birth Rate is

less in those conceived before beginning
dialysis

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Women who Start Dialysis

During Pregnancy
Likelihood of infant surviving is good
Termination of a pregnancy after renal function
has begun to deteriorate rarely rescues the
kidneys
NEJM, Jones and Hayslett, 1996, looked at 82
pregnancies in 67 women w/CRI, only 15% of
those w/deteriorating renal function had a return
of renal function to baseline in 6 mths post
partum

Hou, et al, 1998

Hou, et al, 1998

Hou, et al, 1998

Survival Statistics
One year survival of women 14-44 yrs on
dialysis is 90%
Risk of death for dialysis pt who becomes
pregnant is not increased by the pregnancy
Extreme vigilance required to safeguard health
of pregnant dialysis pts