Dialysis in pregnancy

Dialysis in pregnancy
Dr: Hayam H.Mansour
Professor of internal medicine &Nephrology
Al-Azhar University

Physiological changes in pregnancy

Anatomic changes during pregnancy
 Kidney increase in size (can increase up to 2 cm in
length).
 Increase in vascular volume.
 Increase in interstitial space and glomerular size.
 The greatest changes are seen in the collecting system,
where the calyces, renal pelvis and ureters dilate.

The changes evident by the 3rd month of gestation and
persist until 12 week post partum.
 Stasis of at least 200 ml of urine occurs in collecting system.
 The increased susceptibility of pregnant women to
asymptomatic bacterurea to acute pyelonephritis is
attributed to urinary stasis.

 Pregnancy induces increase in synthesis of prostaglandin
E2 (PGE2) which inhibits ureteral peristalsis and may be
responsible for the hypomotility .
Increase estrogen and progesterone causes hypertrophic
changes in urinary tract resulting in hypomotility of the
urinary tract.
Mechanical obstruction by enlarged uterus can contribute
to ureteral distension.

Functional renal changes during pregnancy
Increase CO and renal VD(40 %) → increase RBF .
The increase in RBF →↑ in GFR.
This changes begins during 1st few weeks after
conception ,it is great at the beginning of 2nd trimester
and remains until after delivery.
Systemic VD → decrease vascular resistance →
decrease in systemic blood pressure.

Creatinine, urea and uric acid clearance increase
therefore serum levels decrease during pregnancy.
Glucosoria irrespective of blood glucose level.
 Amino acids, proteins, water soluble vitamins are
excreted during normal pregnancy due to increase in
GFR.
Increase body water by 6-8 litters.
Na decrease by 4-5 meq/l due to increase plasma volume.

 Plasma osmolarity level decrease by 10 mosm/l.
These may suppress ADH so leads to diuresis.
Osmoreceptors reset at lower level to avoid
continuous diuresis.
Plasma renin concentration 5-10 times greater in
pregnancy .

However the pregnant lady is extremely resistant to
vasopressor effect of angiotensin II.
May be due to increase level of aminopeptidase which
destroy angiotensine II.
Placenta converts some 25-hydroxyvitamin D3 to 1,25-
dihydroxyvitamin D3.

Relationship between pregnancy and kidney disease
Effect of pregnancy on kidney
disease
Effect of kidney disease on
pregnancy
- Worsening proteinuria.
- Deterioration of renal
function.
- Hypertension and
preeclampsia.
- Infertility.
- Abortion
- Preterm delivery.
- IUGR.
- Preeclampsia.
- Polyhydramnios.

Pregnancy in CKD is it possible???
 Decrease fertility:
- Hyper-prolactenemia.
- luteinizing hormone (LH) levels are elevated.
- Hypothalamic pituitary dysfunction.
- Women with ESRD may undergo menopause earlier
(median age 47)
- Anemia.
- Medications.

Pregnancy in CKD is it possible???
Depression and decrease sex drive:
- Eighty four percent reported sexual dysfunction and
only 35% of women reported being sexually active
- Negative body image (potentially related to the
presence of catheters and fistulas) contribute to low
libido.

Why it can happen???
 Due to improvement of the efficacy of dialysis.
Improve treatment of anemia.
Change in counseling practices.
Improve in sex drive of the patient and in general
condition.

Pregnancy Incidence
• Hemodialysis
• Prior to 1976, there were no reported pregnancies in the registry,
with rates increasing to 0.67 pregnancies per 1,000 person-years
from 1986 to 1995.
• 1996–2008. 3.3 pregnancies per 1,000 person-years.
• A recent metaanalysis noted a large increase in number of
reported cases of pregnancy in women on hemodialysis (616
pregnancies from 2000 to 2014) .
• where 7 out of 45 women receiving intensive dialysis became
pregnant.
Nephrol DialTransplant 2016;31:1915–1934

Pregnancy Incidence
• Peritoneal dialysis:
• Pregnancy rates in women on PD are lower than on hemodialysis.
• United States, 1.1% of reproductive age women on PD conceived
versus 2.4% on hemodialysis.
• A hypothesis is that hypertonic dextrose solutions and the fluid
filled peritoneum interfere with ovum transit to the uterus.

Diagnosis of pregnancy in dialysis patients??
 Pregnancy usually unexpected.
Symptoms in the early phase may mimic different diseases and
complications of dialysis.
- Irregular cycles & an anovulatory.
- Abdominal pain, nausea, vomiting and fatigue.
Serum levels of beta-HCG may be increased even in the absence of
pregnancy.
Urine pregnancy test difficult due to anuria.

Diagnosis of pregnancy in dialysis patients??

The pre-pregnancy factors predicting
outcome
Degree of renal impairment rather than the aetiology
of renal disease.
Control of hypertension.
Degree of proteinuria.

Management of dialysis pregnant lady

Management of dialysis pregnant lady
 Discontinuation of teratogenic medications with substitution for
pregnancy-safe options.
 low-dose aspirin is recommended for the prevention of
preeclampsia (stop between 34 and 36 weeks if on heparin).
 Down syndrome screening requires confirmation:
 Ultrasound measurement for nuchal translucency.
 Cell-free DNA.
 Amniocentesis.

Role of nutrionist
Protein intake:
Because of 10-15 g of amino acids can be lost daily in the
dialysate, higher intake 1.5–1.8 g/kg/day is recommended
+10- 20 g/day.
Caloric intake of 35 kcal/kg pregnant weight +300 kcl/day
Folic acid and water soluble vitamins should be
supplemented

Role of nutrionist
• Phosphate: monitored frequently- may stop phosphate
binders or need supplementation (important to fetal
skeletal development)
• Phosphate supplementation is often necessary orally or
by addition of sodium phosphate to the dialysate.
• Calcium: increase dialysate calcium to 1.75 mmol/l – oral
supplementation (1-2 g/d).

Role of obstetrician
Adequate fetal monitoring.
Prevent preterm birth.

• Prevent preterm birth:-
 Indomethacin
 Corticosteroids
 Iv mg
 CCB
 Umbilical artery Doppler measuring velocity flow / 2
weeks

• Monitoring of cervical competency and amniotic fluid levels.
• Cervical incompetence appears to be more common in
women with ESRD compared to the general population.
• Cerclage may be necessary to prevent preterm delivery
among women with ESRD on intensive hemodialysis.

• Delivery :-
Target 38 weeks unless complications nessicitating
delivery.
Kidney disease is not an indication for CS, only
indicated like non HD patients.
Newborn should be in high risk units as he usually
have blood urea similar to mother ,so may suffer
osmotic diuresis.

Role of nephrologist
• Control of Blood pressure:-
- Diastolic 80-90mmhg.
- Very critical ,need controlling Bl P without compromising
uteroplacental circulation.
- In pregnant lady adjustment of UF is very difficult.
- If the patient have preeclampsia , we have to take care as fluid
extraction exacerbate hypoperfusion to various organs

Role of nephrologist
• Antihypertensive drugs:-
Alpha methyl dopa.
Beta Blockers.
Arterial VD.
Calcium channel blockers.
ACEI/ARBS & diuretic are contraindicated during pregnancy

Hemodialysis prescription
Duration of HD
- More than 20 hour/week .
- Shift to night dialysis.
- Target BUN <50 mg/dl.
Increase HD duration:
- Increase conception.
- Decrease incidence of preeclampsia
- Decrease incidence of polyhydramnios

Intensive Hemodialysis Associates with Improved Pregnancy
Outcomes: A Canadian and United States Cohort Comparison

• Dialysate:-
• Increase K to 3 – 3.5 meq/l.
• HCO3 to 25 meq/l.
• Stop phosphate binders.
• Calcium in dialysate 1.72-2.5mmol/l + oral Ca 1.5-2 g/day.
• Na 135 mml/l

•Dialyzer:
low flux.
• Reduce UF rate per session.
• Avoid hypotension.
• Avoid abrupt osmolarity changes.
High surface area membranes.

• Blood flow:
- Gradually increased over 1st 30 minutes of HD, from 180 to
300 ml/min.
- Dialysate flow

• Heparin :
• Pregnancy is a hypercoagulability state.
• Theoretically there are increased requirements.
• It is safe to use heparin whenever there is no vaginal bleeding

Minerals and water soluble vitamins
• Give at increased doses, because they can be partially
removed by intensive dialysis.
• Folic acid at a higher dose of 5 mg daily if on dialysis

•UF & dry body weight assessment
body weight gain in pregnancy
Body weight gain 1 to 2 kg during the first three months then 0.5 kg a
week during the rest of pregnancy

• Anemia:
• Target : 10 -11g/dl.
• EPO : Increase dose by 50- 100%.
• Iron : monitored monthly Iron sucrose is the preferred form of
intravenous iron during pregnancy
• CBC weekly.

Dialysis in left lateral decubitus position

Conception
• All sexually active women who have normal cycles should
advised to use contraception specially if serum creatinine >3
mg/dl as poor outcomes with advanced kidney disease
• Types of contraception
• Oral not contraindicated( Access & lupus).
- Intrauterine device bleeding and infection .
- Barrier method is the best
- .

Post partum
•Breast feeding :-
• There are no known contraindications to breastfeeding in
women with ESRD on hemodialysis.
• Significant variations in breast milk composition between pre
and post-HD samples suggest that breast feeding might be
preferably performed after dialysis treatment.

Post partum
• ACE inhibitors may be used post-partum for women
who benefit from renin-angiotensin-aldosterone system
blockade for blood pressure management
• ESAs and iron can be continued.
• Emotional support is also essential.

Management of pregnant women on hemodialysis

Dialysis in pregnancy

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