#NKFClinicals 2018: My Dialysis Patient Is Pregnant. What Should I Do?

Obstetric Nephrology: A Case-Based Approach Session (April 11, 2018)

Moderator: Mala Sachdeva

Highlights from this session:

  • Differential diagnosis if proteinuria during pregnancy:
    • Proteinuria and hyperfiltration (15th to 38th week),
    • Proteinuria and glomerular disease,
    • Proteinuria related to preeclampsia (>20 weeks), or
    • Superimposed preeclampsia.
  • Plasma creatinine falls significantly during pregnancy and should not be greater than 0.8 mg/dL. This decrease has clinical significance in that a “normal”  creatinine level in a pregnant patient may actually indicate underlying renal disease.
  • Differential diagnosis of worsening HTN during pregnancy:
    • Worsening of hypertension
    • Preeclampsia
    • Other hypertensive disorders of pregnancy
  • Women with creatinine < 1.3 to 1.4 seem to do quite well, with relatively insignificant changes in GFR.
  • Women with moderate renal impairment: 40% experienced a decline in GFR, 10-20% progressed to ESRD.
  • Risk factors for progression of kidney disease during pregnancy:
    • Pre-pregnancy proteinuria (>1g)
    • Pre-pregnancy creatinine (degree of renal dysfunction)
    • Some evidence suggests that proteinuria with any underlying CKD may have more of a detrimental effect on the kidney
    • Extent of comorbidities (hypertension and proteinuria, DM)
    • Worsening hypertension is certainly a poor prognostic indicator and is probably a direct contributor to worsening renal function
    • Urinary tract infection
  • There is a 44% preeclampsia rate in ESRD patients getting pregnant.
  • 66% of nephrologists stated they are somewhat comfortable to very uncomfortable caring for a pregnant woman on hemodialysis.
  • Provide 4 to 4.5 hours of hemodialysis per session  for 6 days/week for the pregnant patient.
  • What should one do when an ESRD patient becomes pregnant?
    • Intensify treatment: dialyze 6 days a week for 4 hours each session.
    • Offer counseling from the high-risk OB/nephrology group to discuss risks/benefits involved with the pregnancy and options to terminate or continue the pregnancy.
    • Discontinue any medication that is teratogenic (ACE, ARBS, etc), maintain hemoglobin with ESA, one can use heparin (stopped towards end of pregnancy in case emergent surgery is needed).
    • Prescribe synthetic vitamin D as needed; as placenta converts 25 D3 to 1,25 D3 ,adjust Vitamin D based on PTH, Ca, Phos, Vitamin D levels. Many of these patients have required oral phosphorus supplementation
    • Not recommended to use ddavp at time of delivery if C-section is done as our BUN is usually less than 20 mg/dL
  • Perform weekly labs. If dialysis is started before arm access is placed, our access of choice is a graft which we can cannulate within one week of placement (allows removal of hemodialysis catheters early on).
  • Changes in our dialysis prescription:
    • Higher Blood Flow Rates for better clearances
    • Maintain a target BUN <20mg/dl
    • Monitor and adjust dry weight weekly, accounting for maternal weight gain and fetal weight gain
    • Higher potassium baths are generally used due to hypokalemia that can result from more frequent dialysis sessions
  • Utilize intradialytic fetal monitoring in an outpatient hospital setting once fetus is viable – should any complications arise during the dialysis treatment, the patient is already in the hospital.
  • Any sign of an upward blood pressure trend alerts us to the possibility of preeclampsia for which we then suggest to hospitalize the patient for close blood pressure monitoring.
  • Assemble a good multidisciplinary team involving internists, obstetricians, nephrologists, nutritionists, and social workers.

– Post prepared by Kenar Jhaveri, AJKD Social Media Advisory Board member. Follow him @kdjhaveri.

The NKF Spring Clinical Meeting abstracts are available in the April 2018 issue of AJKD. Check out more AJKDBlog coverage of #NKFClinicals!

1 Comment on #NKFClinicals 2018: My Dialysis Patient Is Pregnant. What Should I Do?

  1. Valentina De Paz // April 25, 2018 at 10:23 pm // Reply

    Excelentes recomendaciones para el cuidado del binomio: Madre e hijo.

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