Renal Failure and Dialysis in Pregnancy

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Renal Failure and Dialysis in Pregnancy

• David Shure

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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
• Conpoor evidence for DM
• 4. FMD - Pro unequal sized kidneys, young
  female, HTN hx, renal arteries not commented on
  in US

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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

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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

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Normal Physiologic Alterations of Pregnancy
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Normal Renal Alterations in Pregnancy
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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

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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

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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

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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

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Actually, they do get pregnant!

• 1st successful term pregnancy in 35 y/o dialysed
  pt in 1971, Confortini, et al.
• Yr 2000 gt15,000 women of childbearing age
  getting dialysis
• For every person w/CKD 5, 20 have CKD 3 or 4
  w/GFR lt60, suggesting 300,000 women w/CKD
  potentially able to bear children

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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

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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 lt50
• 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

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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 wgt100g protein/ day

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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

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Common Themes in Dialysing Pregnant Patients

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

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BUN lt50 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

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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

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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

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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.

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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 (lt2500 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

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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.

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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

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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

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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

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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

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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 (plt.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

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Hou, et al, 1998
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Hou, et al, 1998
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Hou, et al, 1998
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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