ESRD and pregnancy
- 1. ESRD AND PREGNANCY INTENSIVE HD AND PD Nikhil Shah Home Dialysis Therapies Fellow University of Alberta
- 2. CKD AND ESRD + PREGNANCY • Pregnancy in CKD and especially in ESRD is considered high risk • Several studies have shown that CKD leads to adverse fetal and sometimes maternal outcomes • However with advances in the dialysis techniques and as we know more how to dialyze these precious patients outcomes are improving • 1980 the successful outcome rate was only 23% 1, in 1998 this increased to 50%2 and during the last decade reached the 81.3%. 3 1 Successful pregnancies in women treated by dialysis and kidney transplantation: Report from the registration committee of the European Dialysis and Transplant Association. Br J Obstet Gynaecol. 1980; 87 :839–845. 2 Bagon JA, Varnaeve H, DeMuylder X, Lafontaine JJ, Marten J, Van Roost G. Pregnancy and dialysis. Am J Kidney Dis . 1998; 31 :756–765. 3 Piccoli GB, Conijin A, Consiglio V, et al. Pregnancy in dialysis patients: Is the evidence strong enough to lead us to change our counseling policy? Clin J Am Soc Nephrol 2010; 5 :62–71.
- 3. REASONS FOR SEXUAL DYSFUNCTION AND INFERTILITY • Sexual dysfunction • anemia, • polypharmacy, • depression, • loss of sexual desire, • difficulties in marital life result in reduced conception. • Infertility • Hormonal Imbalance • hormone (FSH) levels are comparable to or slightly lower than those in nonuremic controls, • luteinizing hormone (LH) levels are elevated • fail to have the luteal surge in LH • Both progesterone and estradiol levels are extremely low • prolactin levels are higher • subclinical hypothyroidism • altered levels of HCG • reduced renal leptin clearance, • Anovulatory cycles Mantouvalos H, Metallinos C, Makrygiannakis A, Gouskos A: Sex hormones in women on hemodialysis. Int J Gynaecol Obstet 22:367–370, 1984 Lim VS, Henriquez C, Sievertsen G, Frohman LA: Ovarian function in chronic renal failure: evidence suggesting hypothalamic anovulation. Ann Intern Med 93:21–27, 1980 Gomez F, de la Cueva R, Wauters JP, Lemarchand-Beraud T: Endocrine abnormalities in patients undergoing long-term hemodialysis. The role of prolactin. AmJMed 68:522–530, 1980 Hou SH, Grossman S, Molitch ME: Hyperprolactinemia in patients with renal insufficiency and chronic renal failure requiring hemodialysis or chronic ambulatory peritoneal dialysis. Am J Kidney Dis 6:245–249, 1985
- 4. WHAT IS THE INCIDENCE ON HD AND PD • European Dialysis Transplant Association – 1970s • That registry collected data from 67 centers in 16 countries (approximately 13,000 women), and reported pregnancy to be an exceedingly rare event (<1%). • Belgium -1996 • 32 dialysis centers, representing 1472/4135 patients of were women of childbearing age • incidence rate of pregnancy progressing beyond the first trimester to be 0.3 per 100 patient-years (15 cases) • Japanese national registry • 172 pregnancies occurring in 38,889 women on dialysis, a calculated conception rate of only 3.4%. • Saudi Arabia • HD – 5-7.5% • PD – 0% • US • slightly higher rate of 2.4% of hemodialysis patients became pregnant over a 4-year period (1992–1995) compared to 1.5% previous incidence. • For PD 1.1% • Canada – Toronto • seven pregnancies in 45 women of childbearing age on nocturnal hemodialysis for a pregnancy rate of 15.9%
- 5. COMMON COMPLICATIONS • 80% of perinatal morbidity and mortality due to prematurity • 57% intrauterine growth retardation • 71% polyhydramnios • 14 – 80% respiratory distress syndrome • Low Birth weight (1511+/- 284 g) • NICU stay 7-95 days • 5.8% of pregnancies are spontaneously miscarried, • 71% of them end in preterm labor (mean gestational age 32.9 6.7 weeks) • 37% of them undergo caesarian section • 30.2% maternal hypertension • Infant malformations and Maternal Mortality are similar to general populations Yang LY, Thia EWH, Tan LK. Obstetric outcomes in women with end-stage renal disease on chronic dialysis: A review. Obstr Med . 2010; 3 :48–53
- 6. COMPARED TO HD – PD HAS MORE PROBLEMS • Peritonitis could conceivably damage fallopian tubes, but the rate of ectopic pregnancies reported in this patient population is not increased. • Hypertonic solutions in the intraperitoneal space may interfere with ovum transport from the ovaries to the fallopian tubes. • Abdominal fullness, discomfort, catheter drainage difficulties, and polyhydramnios necessitating a progressive decline in fill volumes • Bloody dialysate can herald an obstetric catastrophe including • placental abruption • secondary to trauma to the expanding uterus from the peritoneal dialysis catheter • Preterm delivery, premature rupture of membranes, and stillbirth to occur secondary to acute peritonitis
- 7. CANADIAN EXPERIENCE – TORONTO REGISTRY • The Toronto Pregnancy and Kidney Disease (PreKid) Clinic and Registry • 22 pregnancies in 17 patients • 18 pregnancies when patient already on dialysis, 4 started HD during pregnancy • Toronto group was significantly older than the American patients (34 +/- 4yrs versus 27+/- 6 years; P <0.001) • American Registry for Pregnancy in Dialysis Patients (ARPD) • 70 pregnancies – 57 in patients on dialysis, 13 started during pregnancy
- 9. DIALYSIS INTENSITY PROPORTIONAL TO OUTCOMES
- 10. DIALYSIS INTENSITY PROPORTIONAL TO OUTCOMES
- 11. COMPLICATIONS Canadian Cohort • All except 2 patients delivered vaginally • Short cervix, precipitous delivery and need for cervical cercelage – 4 patients • Transient polyhydramnios – 1 patient • PreEclampsia – 1 patient • Placental insufficiency – 3 patients • First trimester loss – 1 patient American Cohort • the mean gestational age - 32.7 +/- 3.1 weeks • mean gestational weight of 1554+/-663 g. • Preeclampsia (19%), • polyhydramnios (40%), • transfusions (25%), • hypertension (70%)
- 12. Asamiya Y, Otsubo S, Matsuda Y, Kimata N, Kikuchi K, Miwa N, Uchida K,MineshimaM,MitaniM,Ohta H, Nitta K, Akiba T: The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int 75: 1217–1222, 2009
- 13. PD DATA • Redrow at al • described 14 pregnancies of which 4 ended in spontaneous abortion • Four were patients approaching ESRD who were started on either peritoneal dialysis (n = 2) or hemodialysis(n = 2), and therefore had significant residual renal function • three established peritoneal dialysis patients delivered babies weighing 1065–1720 g between 32 and 34 weeks of gestation, whereas the hemodialysis patients delivered babies weighing 2044 and 2218 g at 35 and 36 weeks of gestation, respectively • Several case reports – small numbers, difficult to interpret results • Most cases would report a slight benefit of HD
- 14. HOW DOES PD HELP • PD offers specific benefits for management of the pregnancy, • such as more continuous and gentle daily ultrafiltration, • metabolic balance without the fluctuations noted in intermittent therapies, • less anemia, • avoidance of systemic anticoagulation, • more liberal diet for maintaining maternal nutrition • But, data is from 1980s and 90s before intensive hemodialytic therapies were widely adopted. Redrow M, Cherem L, Elliott J, Mangalat J, Mishler RE, Bennett WM, et al. Dialysis in the management of pregnant patients with renal insufficiency. Medicine (Baltimore) 1988; 67:199–208. Jakobi P, Ohel G, Szylman P, Levit A, Lewin M, Paldi E. Continuous ambulatory peritoneal dialysis as the primary approach in the management of severe renal insufficiency in pregnancy. Obstet Gynecol 1992; 79:808–10.
- 16. PD PRESCRIPTION • Most common – • Less volume ~ 1.5L • More exchanges – 4-6 /day • APD • 1.5 – 2L exchanges x 4 • Plus 1-2 day exchanges • No report of Icodextrin! • Residual renal function important Batarse RR, Steiger RM, Guest S. Peritoneal Dialysis Prescription During the Third Trimester of Pregnancy. Perit Dial Int. 2015 Mar 1;35(2):128–34.
- 17. WHY DOES INTENSE DIALYSIS HELP • clinical (BP, left ventricular hypertrophy), • biochemical (urea and phosphate clearance, anemia), • biologic parameters (endothelial function, inflammation), • clearance of urea and likely other solutes. • negative relationship was noted between • BUN and birth weight (r=20.53, P=0.02) • BUN and gestational age (r=20.50, P=0.02). • Birth weight of at least 1500 g was achieved at a BUN of 49 mg/dl (urea 17.9 mmol/L) • Gestational age of at least 32 weeks was achieved at a BUN of 48 mg/dl (urea 17.1 mmol/L). • Residual renal function • improve pregnancy outcomes • live birth rates favored women who conceived before the initiation of dialysis compared with established dialysis patients • Women with more residual kidney function requiring less intensive dialysis Asamiya Y, Otsubo S, Matsuda Y, Kimata N, Kikuchi K, Miwa N, Uchida K,MineshimaM,MitaniM,Ohta H, Nitta K, Akiba T: The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int 75: 1217–1222, 2009
- 18. MANAGEMENT Vázquez JAG, Calva IEM, Fernández RM, León VE, Cardona M, Noyola H. Pregnancy in End-Stage Renal Disease Patients and Treatment with Peritoneal Dialysis: Report of Two Cases. Perit Dial Int. 2007 May 1;27(3):353–8.
- 19. MANAGEMENT • Medication review • Stop RAS inhibitors • Stop Statins • Review Immunosuppression if any • Diet • Double dose of Multi Vitamins • Folic acid 5 mg PO daily • “Unrestricted diet” • Protein 1.5 – 1.8 g/kg/d • Dialyzate bath • Potassium 3.0 • Bicarb 25 • Calcium 1.75 • Sodium Phosphate – add to bath • Anemia • Increase EPO to weekly / double the dose • IV and oral iron • Target Hb 110
- 20. MANAGEMENT • DW – • During the first trimester, expected weight gain is minimal – 0.5 kg/ month. • while during the second and third trimesters, the dry weight can be expected to increase by up to 0.5 kg⁄ week. • Calcium and Phosphorus • Within normal limits for your lab • PTH • Within KDOQI guidelines for non pregnant patients • Targets • Urea - ~10 mmol/L • Hemoglobin – 10 -11 g/l • BP - <130 /80 • Use MethylDopa, Labetolol, Nifedepine, Hydralazine Barua M, Hladunewich M, Keunen J, Pierratos A, McFarlane P, Sood M, et al. Successful Pregnancies on Nocturnal Home Hemodialysis. CJASN. 2008 Mar 1;3(2):392–6.
- 21. Barua M, Hladunewich M, Keunen J, Pierratos A, McFarlane P, Sood M, et al. Successful Pregnancies on Nocturnal Home Hemodialysis. CJASN. 2008 Mar 1;3(2):392–6.
- 22. Barua M, Hladunewich M, Keunen J, Pierratos A, McFarlane P, Sood M, et al. Successful Pregnancies on Nocturnal Home Hemodialysis. CJASN. 2008 Mar 1;3(2):392–6.
- 23. DIAGNOSIS OF PREECLAMPSIA IN ESRD • diagnosis of preeclampsia relies on the assessment of • worsening blood pressure • alterations in placental Doppler blood flow, • Fetal growth restriction, • hematological alterations - suggestive of the HELLP Syndrome (elevated liver transaminases and decreased platelets). • Newer tests? • sFLT1
- 24. MAIN FACTORS FOR SUCCESS • Intensive dialysis • Erythropoietin • Calcium and phosphorus management • BP management • Maternal nutrition • Iron and Folate supplementation • Monitoring - Maternal • Monitoring – Fetal • Compliance
- 25. ROLE OF THE FETAL MEDICINE AND OBSTETRIC SPECIALISTS • Fetal Monitoring • First trimester screen (nuchal translucency, PAPP-A, bhCG) between 9 and13 weeks) • Maternal serum screen (AFP, total hCG, inhibin A and unconjugated estriol) between 15 and 18 weeks • Level II US tomeasure cervical length and assess for anomalies at 18–20 weeks • Placental US with Doppler assessment at 22 weeks • Weekly US and BPP from 26 weeks until delivery • Obstetric monitoring • Cervical insufficiency • Steroids to promote lung maturity • Premature labour • Progesterone administration? • Bleeding • Cesarean section • Lactation +/- suppression • Neonatal Monitioring • Apgar scores • NICU? • IUGR/SGA/Premie • Growth charting/ Milestones • Defects – cognitive or physical?
- 26. THANK YOU