1 / 42

Renal Failure and Dialysis in Pregnancy

Renal Failure and Dialysis in Pregnancy. David Shure. 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

johana
Download Presentation

Renal Failure and Dialysis in Pregnancy

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Renal Failure and Dialysis in Pregnancy David Shure

  2. 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 Con:poor evidence for DM 4. FMD - Pro: unequal sized kidneys, young female, HTN hx, renal arteries not commented on in US

  3. 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

  4. 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

  5. Normal Physiologic Alterations of Pregnancy

  6. Normal Renal Alterations in Pregnancy

  7. 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

  8. 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

  9. 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, doesn’t the egg just float away?’, Rodby, 1992

  10. Why don’t uremic women get pregnant? • Most beyond child bearing age • Libido/ frequency of intercourse reduced • Don’t ovulate • Absence of increase in basal body temperature during the luteal phase of cycle • Elevated circulating prolactin concentrations • Elevated PRL impairs hypothalamic-pit function

  11. Actually, they do get pregnant! • 1st successful term pregnancy in 35 y/o dialysed pt in 1971, Confortini, et al. • Yr 2000: >15,000 women of childbearing age getting dialysis • For every person w/CKD 5, 20 have CKD 3 or 4 w/GFR <60, suggesting ~300,000 women w/CKD potentially able to bear children

  12. 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

  13. 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 <50 • 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

  14. 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 w>100g protein/ day

  15. 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

  16. Common Themes in Dialysing Pregnant Patients 1. Keeping BUN < 50 2. Increasing dialysis time and frequency 3. BP control 4. Managing anemia with increasing doses of ESA 5. Fetal monitoring once viability reached

  17. BUN <50 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

  18. 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

  19. 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

  20. 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.

  21. Characteristics of Personal Cases

  22. Pt #12: initially treated in a ctr in which target Hb levels were lower than 10-12

  23. Pt #13, s/p parathyroidectomy just before conception

  24. Pt #14

  25. 5 Highlighted Cases Are Those Started on HD after Pregnancy

  26. Case Characteristics/ Outcomes • 4/5 cases survived, 1 in-utero death • All deliveries preterm • All w/ low birth wt (<2500 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

  27. 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.

  28. 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’’

  29. 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

  30. 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

  31. 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

  32. Registry includes ~ 48% of women of childbearing years receiving HD in US 1992-1995

  33. 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

  34. Women who conceived after start dialysis, 40.2% infants survived, c/w 73.6% in women who started dial after conception (p<.001)

  35. Frequency of Prematurity and Low Birth Rate is less in those conceived before beginning dialysis

  36. 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

  37. Hou, et al, 1998

  38. Hou, et al, 1998

  39. Hou, et al, 1998

  40. 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

More Related