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Renal Failure and Dialysis in Pregnancy

Renal Failure and Dialysis in Pregnancy. David Shure. Differential Diagnosis. 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

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Renal Failure and Dialysis in Pregnancy

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  1. Renal Failure and Dialysis in Pregnancy David Shure

  2. Differential Diagnosis • 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 4. FMD - Pro: unequal sized kidneys, young female, HTN hx, renal arteries not commented on in US

  3. Nephrology Consult • Is there any indication and/ or benefit to the fetus if we begin HD at this time? • 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

  4. 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

  5. Normal Physiologic Alterations of Pregnancy

  6. Normal Renal Alterations in Pregnancy

  7. 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

  8. Effects of Pregnancy on Renal Disease • ½ cases proteinuria worsen • ¼ cases HTN develops • Worsening edema if nephrotic • 0-10% women with NL or mild reduction in GFR have permanent decline in renal function

  9. 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, doesn’t the egg just float away?’, Rodby, 1992

  10. Why don’t uremic women get pregnant? • Most beyond child bearing age • Libido/ frequency of intercourse reduced • Don’t ovulate • Absence of increase in basal body temperature during the luteal phase of cycle • Elevated circulating prolactin concentrations • Elevated PRL impairs hypothalamic-pit function

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. Pregnancy and DialysisBagon, 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 1975-1996

  20. 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.

  21. Characteristics of Personal Cases

  22. Pt #12: initially treated in a ctr in which target Hb levels were lower than 10-12

  23. Pt #13, s/p parathyroidectomy just before conception

  24. Pt #14

  25. 5 Highlighted Cases Are Those Started on HD after Pregnancy

  26. 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

  27. 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.

  28. 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’’

  29. 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

  30. 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

  31. 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

  32. Registry includes ~ 48% of women of childbearing years receiving HD in US 1992-1995

  33. 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

  34. Women who conceived after start dialysis, 40.2% infants survived, c/w 73.6% in women who started dial after conception (p<.001)

  35. Frequency of Prematurity and Low Birth Rate is less in those conceived before beginning dialysis

  36. 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

  37. Hou, et al, 1998

  38. Hou, et al, 1998

  39. Hou, et al, 1998

  40. 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

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