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Protocol of hemodialysis in pregnancy
- 1. Protocol of Hemodialysis inPregnancy DR MOHAMED AL-AMIN
- 2. Patient education andcounselling sessions Pre-dialysis and dialysis education program Education elements: Conception rates: 40% of dialysis women under the age of 55 being able to continue to menstruate. Contraception options: contraception should be encouraged for women who do not want to conceive. However, Intrauterine devices are discouraged as they can increase bleeding during heparin use on dialysis and oral contraceptives are contraindicated for women with a history thrombophlebitis or lupus. Pregnancy complications: spontaneous abortion, Fetal death, distress and preterm delivery; Hypertension; Preeclampsia, Polyhydramnios or oligohydramnios.
- 3. Statistics ofa live baby: Urea has been shown to be directly proportional to fetal mortality Live birth rates were significantly higher in women who received more than 36 hours of dialysis per week than in those who received 20 hours or fewer per week (85% vs 48%; P = .02). Fetal survival rates for pregnant women on haemodialysis have also increased to 87%, with an average gestational age of 32.7 +- 3.1 weeks. Additional haemodialysis requirements during pregnancy. Tests involved in caring for a pregnant woman on Haemodialysis Patient education and counselling sessions
- 4. Staff managing patient Dialysis unit head nurse should assign a core group of highly trained senior nurses to dialyse the pregnant woman to ensure continuity and advanced care is achieved.
- 5. Multidisciplinary team work The pregnant hemodialysis patient should be cared with team work including nephrologist, dialysis nurse, obstetrician, social worker and dietician. Frequent meetings and communications between team members should be planned and arranged.
- 6. Hemodialysis Prescription Durationand frequency: duration should be at least 20 hours per week; 4hx5sessions/week (e.g. Sat, Sun, Tue, Wed, and Thursday). More intensive HD prescription (36hours) showed better outcomes: 6hX6 days/week.
- 7. Dialyzer: Biocompatiblehigh flux dialyzer. Blood flow rate: 200-300 ml/min. it is better to increase BFR gradually during the first 30 min of dialysis. Hemodialysis Prescription
- 8. Anticoagulation Usethe minimal possible dose of heparin (Heparin is safe unless there vaginal bleeding). Tinzaparine sodium (innohep) can be used as a bollus of 1500-2500 IU subcutaneousely. Coumarin should be avoided. Hemodialysis Prescription
- 9. Vitals: Bloodpressure should be monitored every 15 min with target diastolic pressure 80-90mm/Hg. Hemodialysis Prescription
- 10. Dry weight Ultrafiltration goal should be adjusted based on expected pregnancy induced weight gain, but slow rate ultrafiltration is recommended as it is preferred to leave “wet” as opposed to dry to avoid hypotension. Rapid and excessive UF should be avoided. Hemodialysis Prescription
- 11. Dry weight Dry weight should be assessed at each dialysis and reviewed weekly and as required due to: Fetal and placental growth and 30% increase in plasma volume during pregnancy. The expected increase of body weight is 250gm/week till 20th week of pregnancy and 300-500gm/week afterwards. Hemodialysis Prescription
- 12. Dialysate Dialysate flow rate500ml/min. Dialysate components: bicarbonate 25 mmol/l, sodium 138 mmol/l, potassium 3.0 mmol/l, calcium 1.25 mmol/l, chloride 110 mmol/l, and magnesium 0.5 mmol/l. Hemodialysis Prescription
- 13. Hyperension BP shouldbe kept ≤ 140/90 mm/Hg. Recommended antihypertensive drugs in the following order: alpha methyldopa, BB (labetalol and not atenolol), hydralazine and calcium channel blocker (nifedipine, nicardipine, and verapamil). Avoid diuretics, ACE inhibitors, and ARB. Avoid hypotension and volume depletion. Drugs for hypertensive emergency are intravenous labetalol and hydralazine.
- 14. Anemia Management Erythropoietindose should be increased 50-100% to keep Hb 10-11g/l. Iron: It should not be given in the 1st trimester. Iron requirements should be increased to 200 mg IV weekly Mentain TSAT > 25 %.
- 15. Bone Disease Calciumsupplements and phosphate binder should be adjusted according to weekly blood level. Avoid post dialysis hypercalcemia which may be caused due to frequent dialysis (maternal hypercalcemia will cause hypocalcemia and hyperphosphatemia in the newborn and affect skeletal development). Avoid hyperphosphatemia and hypocalcemia.
- 16. Bone Disease Hypophosphatemiamay result from frequent dialysis, so, oral supplement is recommended or increase dietary intake. Vitamin D supplement should be adjusted according to blood level of Vitamin D, calcium, phosphorus. Sevelamer, lanthanum carbonate, aluminium hydroxide, cinacalcet, and paricalcitol are not recommended.
- 17. Nutrition Dietician shouldregularly visit the patient and modify the nutritional plan according to the coordinated team work meetings. Minimum daily intake of protein should be 1.8g/kg. Calorie intake of 35kcal/kg/ pregnant weight/day +300kcal/day.
- 18. Nutrition Supplements Folicacid 2mg/day. Calcium carbonate 1500mg/day. Vitamin D: 1000 iu daily. Calcitriol: adjust according to level of calcium and phosphorus level. Supplements of water soluble vitamins that can be dialyzed (Vitamin C, thiamine, riboflavin, niacin, vitamin B6 and vitamin B12). Zinc 15 mg daily. Potassium, Calcium, Phosphorus and bicarbonate: Values for these parameters should be monitored closely in pregnant patients so that treatment can be individualized.
- 19. Blood Investigations Weeklyand PRN blood result for U&Es, bone profile, vitamin D, LFT and CBC. Pre-dialysis urea should be kept < 15 mmol/l. Pre-dialysis creatinine should be kept < 550 umol/l. PH should be maintained >7.2. Vitamin D and iPTH level should be checked every trimester. Calcium supplements should be adjusted according to the weekly blood level (Production of calcitriol by the placenta may increase the patients calcium).
- 20. Positioning The pregnantwoman should be positioned semi reclined or on a bed with a left lateral tilt from 20 weeks, to ensure decompression of vena cava.
- 21. Antenatal monitoring Antenatalvisits are recommended 2/52 then weekly after 32 weeks.
- 22. Delivery Delivery isrecommended between 34-36 weeks and no later than 38 weeks. Neonatal intensive care management is mandatory as even babies born “close to term should be monitored closely, as they generally have solute diuresis and may become seriously volume contracted.
- 23. References Baha di,A., El Kabbaj, D., Guelzim, K., Kouach, J., Hassani, M., Maoujoud, O., Aattif, M., Kadiri, M., Montassir, D., Zajjari, Y., Alayoud, A., Benyahia, M., Elallam, M. & Oualim, Z. (2010). Pregnancy during hemodialysis: A single Center experience. Saudi Journal of Kidney Diseases and Transplantation, 21 (4), 646-651. Bamberg, C., Diekmann, F., Haase, M., Budde, K., Hocher, B., Halle, H. & Hartung, J. (2007). Pregnancy on Intensified Haemodialysis: Fetal surveillance and perinatal outcome. Fetal Diagnosis and Therapy, (22), 289-293. Barua, M., Hladunewich, M., Keunen, J., Perratos, A., McFarlane, P., Sood, M. & Chan, C. T. (2008). Successful pregnancies on nocturnal home haemodialysis. Clinical Journal of the American Society of Nephrology, 3, 392-396. Coyle, M., Sulger, E., Fletcher, C. & Rouse, D. (2008). A successful 39-week pregnancy on hemodialysis: A case report. Nephrology Nursing Journal, 35 (4), 348-402.
- 24. Daugirdas, J.T., Blake, P. G. & Ing, T. S. (2007). Handbook of Dialysis. 4th Ed. Lippincott Williams & Wilkins, Philadelphia, 673-677. Dhir, S. & Fuller, J. (2007). Case report: Pregnancy in hemodialysis-dependent end-stage renal disease: anaesthetic considerations. Canadian Journal of Anaesthesia, 54 (7), 556- 560. Hladunewich MA, Hou S, Odutayo A, et al: Intensive hemodialysis associates with improved pregnancy outcomes: a Canadian and United States cohort comparison. J Am Soc Nephrol. 2014 May;25(5):1103-9. Ind, D. (2007). Pregnancy and renal function. Renal Society of Australasia Journal, 3 (2) 47- 49. Renal Department 2013 Page 6 Luders, C., Castro, M. C, M., Titan, S. M., De Castro, I., Elias, R. M., Abensur, H. & Romao, J. E. (2010). Obstetric outcome in pregnant women on long-term dialysis: A case series. American Journal of Kidney diseases, 56 (1), 77-85. References
- 25. Piccoli, G.B., Conijn, A., Consiglio, V., Vasario, E., Attini, R., Deagostini, M. C., Bontempo, S. & Tudros, T. (2010). Pregnancy in Dialysis Patients: Is Evidence strong enough to lead us to change our counselling policy? Clinical Journal of the American Society of Nephrology, (5), 62-71. Vidaeff, A. C., Yeomans, E. R. & Ramin, S. M. (2008). Pregnancy in women with renal disease. Part I: General principles. American Journal of Perinatology, 25 (7), 385-397. Wilkinson, J. (2007). Motherhood becomes a reality. Renal Society of Australasia Journal, 3 (2) 39-46. References