While it is rare, women on dialysis have become pregnant. Of these pregnancies, about 20 percent will end in miscarriage. A full-term pregnancy lasts about 40 weeks; however, about 80 percent of dialysis pregnancies will only go about 32 weeks, resulting in a premature birth

2. DIALYSIS IN PREGNANCY
 For pregnant women with chronic kidney disease who need
dialysis, two modalities can be offered: HEMODIALYSIS AND
PERITONEAL DIALYSIS
 The treatment modality should not be changed with the onset
of pregnancy; however, if urgent start is necessary, it may be
easier to start with hemodialysis, since the insertion of a
Tenckhoff peritoneal dialysis catheter in any period of
pregnancy increases the risk of miscarriage.
 The pregnancy rate is lower among patients on peritoneal
dialysis compared to those on hemodialysis.

3. CONT….
 In an analysis of registry data including 6,230 women aged 14
to 44 years (1,699 on peritoneal dialysis and 4,531 on
hemodialysis), 2.4% of patients on hemodialysis became
pregnant over a period of four years versus only 1.1% of
patients on peritoneal dialysis.
 During Dialysis When compared to hemodialysis, peritoneal
dialysis enables a more stable uterine environment, without
large fluctuations in blood volume, solutes, electrolytes and
blood pressure.

4. RECOMMENDATIONS IN DIALYSIS
PRESCRIPTION DURING PREGNANCY
 HEMODIALYSIS PRESCRIPTION DURING
PREGNANCY
 PERITONEAL DIALYSIS PRESCRIPTION DURING
PREGNANCY
 BLOOD PRESSURE CONTROL
 ANEMIA
 PHOSPHOROUS-CALCIUM METABOLISM
 ACID-BASE DISORDERS
 NUTRITION

5. HEMODIALYSIS PRESCRIPTION DURING
PREGNANCY
 Increase in dialysis duration to 24 to 36 hours per week ¥ (5 to 7
sessions/week)
 Keep Predialytic urea levels < 30-50 mg/Dl
 Dry weight increase in 300-500 mg weekly in the 2nd and 3rd trimesters
 Minimum needed heparinization. Cumarin anticoagulants are
contraindicated
 Use of biocompatible membranes
 Avoid hypocalcemia. Recommended potassium levels in the dialysate
between 3.0-3.5 mmol/L. Need for weekly electrolyte monitoring

6. PERITONEAL DIALYSIS
PRESCRIPTION DURING PREGNANCY
 Increase the exchange frequency and reduce the volumes (usually <1.5L)
 Adding CAPD and APD to optimize the technique
Blood pressure control
 Target blood pressure after the dialysis session: 140-120/ 70-90 mmHg
 Objective volume monitoring, if possible (bio impedance option)
 Avoid hypotension and volume depression episodes
 Angiotensin Converting Enzyme Inhibitors (ACEI), Angiotensin II Receptors
Antagonists (ARA II) and minoxidil are contraindicated

7. HEMODIALYSIS PROS AND CONS
DURING PREGNANCY
PROS
 Less dietary restrictions
 Less water restrictions
 Less overload using the technique
CONS
 Worse metabolic control (intermittent
dialysis)
 Higher risk of hemodynamic
instability
 Need for hypo coagulation
 Lower autonomy

8. PERITONEAL DIALYSIS PROS &
CONS
PROS
 Better metabolic control
(continuous dialysis)
 Lower risk of hemodynamic
instability
 Higher degree of autonomy
 No need for anticoagulation
 Preserving residual kidney
function
CONS
 Higher risk of infectious complications
 Higher risk of non-infectious
complications
 More difficulty managing volume
 Higher % of intrauterine growth
restriction
 Increase in the frequency of exchanges

9. ANEMIA
 Increase in Erythropoiesis Stimulating Agent (ESA) dose to
maintain the hemoglobin levels of 10-11 g/dL and the
hematocrit between 30% and 35% (a 50-100% increase is
usually necessary)
 Iron supplementation to maintain transferrin saturation above
30%. Oral supplementation is usually not enough, and
intravenous administration may be necessary

10. PHOSPHOROUS-CALCIUM
METABOLISM
 Avoid hypocalcemia and hyperphosphatemia. Weekly
monitoring and calcium carbonate 1-2 g/D supplementation
are recommended, if indicated
 Avoid hypercalcemia after the dialysis. If needed, adjust
dialysate calcium (recommended dialysate calcium dosage of
1.50 mmol/L)
 1,25-di-hidroxivitamin D (calcitriol) is recommended in cases
of primary hyperparathyroidism or vitamin deficiency

11. ACID-BASE DISORDERS
 Avoid metabolic acidosis
 Lower doses of bicarbonate are recommended in the
dialysate (25 mmol/L), because frequent
hemodialysis may increase the risk of metabolic
alkalosis

12. NUTRITION
 Supplementation with folic acid and vitamin B
complex
 Increase protein intake to 1.8 g/kg/D of the pre-
pregnancy weight + 10-20g/D
 Increase the caloric uptake to 35 Kcal/kg of the
weight during pregnancy + 300 Kcal/D

13. MATERNAL AND FETAL
COMPLICATIONS IN DIALYSIS
 The maternal complications most frequently identified in pregnant
women on dialysis are anaemia and high blood pressure.
 The maternal complications most frequently identified in pregnant
women on dialysis are anaemia and high blood pressure
 Two other conditions preeclampsia and HELLP syndrome.
 prematurity is the main one, occurring in about 80% of cases,
followed by restriction of intrauterine growth in 36% of cases, fetal
distress and polyhydramnios.
 More than a quarter of newborns are underweight for their
gestational age, below the appropriate percentile.

14. POST-DELIVERY CARE
 Routine postpartum care for women on dialysis is similar to the
treatment used for those with normal kidney function.
 There are no contraindications for breastfeeding, and it is important
to avoid aggressive ultra filtration, because volume depletion can
interfere.
 Many women resume their pre-pregnancy dialysis programs three
times a week in the postpartum period, since the recommended
numerous sessions during pregnancy are difficult to keep

15. CAUSES OF AKI IN PREGNANCY
PRE-RENAL
 Hyperemesis gravidarum
 Haemorrhage
 Heart Failure
INTRA-RENAL
 Acute tubular necrosis
 Acute cortical necrosis
 Acute fatty liver of pregnancy
 Preeclampsia/HELLP
 TTP/ atypical HUS
 Pyelonephritis
 Amniotic fluid embolism
 Pulmonary embolism
 Lupus nephritis
 Acute Interstitial Nephritis

16. CAUSES OF AKI IN PREGNANCY
POST-RENAL
 Hydronephrosis due to uterine compression
 Injury to ureters or bladder during C-section
 Ureteral obstruction from stones or tumor
 Obstruction at bladder outlet

17. INDICATIONS FOR DIALYSIS
DURING PREGNANCY
 Dialysis should be initiated when the serum creatinine level is
3.5mg/dl
 The GFR is <20ml/min/1.73m2
 When the maternal urea concentration is 17-20mmol/l
 Encephalopathy
 Pericarditis
 Neuropathy
 Volume overload
 Hyperkalemia
 Metabolic acidosis

18. DIALYSIS REGIMEN DURING
PREGNANCY
1. DIALYSIS MODALITY
2. INTENSIVE DIALYSIS
3. DIALYSIS SOLUTION CALCIUM
4. DIALYSIS SOLUTION BICARBONATE
5. DIALYSIS SOLUTION SODIUM.
6. MONITORING WEIGHT GAIN
7. HEPARINIZATION

19. 1.DIALYSIS MODALITY
 In direct comparisons of dialysis modalities, there is no difference in outcome of pregnancy
between hemodialysis patients and peritoneal dialysis patients, as measured by either
infant survival or mean gestational age of live-born infants (Okundaye, 1998).
 However, it is easier to increase the amount of dialysis delivered with hemodialysis.
 The higher success rates reported in more recent studies have been achieved in
hemodialysis patients.
 Although dialysis modality should not be changed because of pregnancy, it may be easier
to start hemodialysis in a pregnant woman than peritoneal.
 If peritoneal dialysis is elected, placement of a peritoneal catheter is possible at any stage
of pregnancy, but immediate use and increased intra-abdominal pressure may increase the
risk of leaking around the catheter.
 There have been instances of mechanical problems with peritoneal catheters with changes
in fetal position.
 Some nephrologists have elected to supplement peritoneal dialysis with hemodialysis
when pregnancy is near term

20. 2.INTENSIVE DIALYSIS
 There is growing evidence that the likelihood of a surviving infant is increased with
intensive dialysis.
 The ideal number of hours of dialysis has not been established. There was a marked
improvement in outcomes for women dialyzed more than 20 hours per week, with a
corresponding decrease in severe prematurity compared with less intense regimens
(Hou, 2010).
 Infant survival was 75% for pregnancies in the group dialyzed more than 20 hours a
week compared with 33% and 44% for less intensively dialyzed groups
 Mean gestational age for babies born to women dialyzed more than 20 hours a week
was 34 weeks compared with 30 weeks in less intensively dialyzed women.
 Even better outcomes have been seen in women undergoing nocturnal hemodialysis 48
hours weekly with most infants surviving and born close to term (Nadeau-Fredette,
2013).

21. CONT….
 In a comparison of pregnancy results in the United States versus Canada, there was a
suggestion of a “dose response” relationship between duration of weekly dialysis and
pregnancy outcomes (Hladunewich, 2014).
 There may be some amount of dialysis between 20 and 48 hours a week that will lead
to satisfactory outcomes.
 Daily dialysis decreases the fluid removal at each treatment, decreasing the risk of
hypotension during dialysis.
 Daily dialysis also allows the patient to eat a high-protein diet to ensure that the needs
of pregnancy are met.
 Increasing the intensity of dialysis in peritoneal dialysis patients is difficult.
 Late in pregnancy, women have difficulty with severe abdominal distension, and
exchange volume may have to be decreased.

22. CONT….
 It becomes necessary to increase the frequency of exchanges even to maintain the same
level of dialysis.
 A combination of frequent daytime exchanges and nighttime cycler is often necessary
 Some have raised the question whether increased
 dialysis might have a detrimental effect by causing electrolyte abnormalities or by removing
progesterone
 Progesterone withdrawal plays a role in the initiation of labor.
 Measurements of serum progesterone levels during dialysis in pregnant dialysis patients
are variable
 Brost and colleagues (1999) measured pre- and post dialysis progesterone levels in seven
pregnant dialysis patients.
 Changes in serum progesterone ranged from a 52% decrease in levels to an 8% increase
(Brost, 1999). Changes in serum progesterone were not associated with changes in home
uterine activity monitoring

23. 3.DIALYSIS SOLUTION CALCIUM
 With the recognition of the risk of soft tissue calcification in long-term dialysis patients, a
2.25 mEq/L (1.125 mM) or 2.5 mEq/L (1.25 mM) calcium concentration has replaced 3.5
mEq/L (1.75 mM) as standard.
 When a bath containing 2.5 mEq/L (1.25 mM) is used, the patient is usually in positive
calcium balance, averaging about 200 mg/treatment.
 There is some production of calcitriol by the placenta that may increase serum calcium.
 Predialysis serum calcium levels should be checked weekly. The fetus needs 25 to 30 g
of calcium for calcification of the fetal skeleton. With a 2.5 mEq/L (1.25 mM) bath, 25
weeks of dialysis should provide enough calcium, but premature birth is common
enough, and calcium flux variable enough, that oral supplementation is advisable.
 If the woman requires phosphate binders, 1 to 2 g of elemental calcium should be
sufficient. Over the long term, dialysate calcium should be low enough to minimize soft
tissue calcification, but over the short term of pregnancy, calcium should be sufficient for
the fetal skeleton. Skeletal abnormalities have been described in one baby born to a
dialysis patient

24. CONT….
 For women who need phosphate binders, calcium-containing binders are the only group
known to be safe in pregnancy. There is no experience with sevelamer or lanthanum
carbonate in pregnancy.
 Lanthanum is neurotoxic in fetal mice. Some women become hypophosphatemic.
 Often, phosphate binders are no longer required, and it may be necessary to add
phosphorus to the bath (e.g., 4 mg/dL [1.3 mM] phosphorus or higher)
 For women who do not need phosphate binders, calcium can be provided in a lower
dose separate from meals.
 Experience with cinacalcet in pregnancy is limited to a few case reports of use in primary
hyperparathyroidism.
 Serum calcium and phosphorus should be monitored weekly. Hypercalcemia may
suppress the fetal parathyroid glands and cause neonatal tetany.

25. 4.DIALYSIS SOLUTION
BICARBONATE
 With a standard bath, daily dialysis carries a theoretical risk of alkalosis.
 Metabolic alkalosis carries an increased risk in pregnant women who
have a concurrent respiratory alkalosis;
 however, in the few instances where arterial blood gases have been
done, compensatory hypercapnia has occurred in women with severe
metabolic alkalosis.
 Serum bicarbonate in normal pregnancy is 18–20 mmol/L. A 25 mM
bicarbonate dialysis bath is usually effective in avoiding alkalosis.
 When this bicarbonate concentration is not available, bicarbonate can be
removed by increasing ultrafiltration and replacing the losses with saline.

26. 5.DIALYSIS SOLUTION SODIUM.
 Normal serum sodium is decreased during pregnancy to
approximately 134 mmol/L. Since thirst is normal, the
pregnant woman will take in enough water to normalize
serum sodium if it is high at the end of dialysis. With daily
dialysis, fluid removal should be modest enough to make
sodium modeling unnecessary.

27. 6.MONITORING WEIGHT GAIN
 Determination of optimal postdialysis weight is problematic in pregnant dialysis patients.
Recommended weight gain for women who become pregnant at their ideal body weight is
11.5–16 kg. Only 1.6 kg of this weight gain occurs in the first trimester.
 During pregnancy, there is a 50% increase in blood volume, but vasodilatation normally
prevents the development of hypertension.
 There is some evidence that blood volume does not increase appropriately in pregnant
women with renal insufficiency, but blood volume has not been studied in pregnant
dialysis patients.
 In early pregnancy, it may become difficult to dialyze the patient down to her prepregnancy
dry weight, but the change should be only 0.9 to 2.3 kg, depending on the prepregnancy
body mass index (BMI).

28. CONT…..
 Recommended weight gain in the second and third trimesters is between 0.3 and 0.5 kg
per week, again depending on the prepregnancy BMI.
 While the nutritionist in the dialysis unit can provide dietary guidelines for appropriate
weight gain during pregnancy, the most pressing question for the dialysis unit staff is
determining how much of the weight change between treatments is excess fluid and how
much is part of the desired pregnancy-associated weight gain.
 With daily dialysis, fluid gain between treatments should be small, but the majority of the
day-to-day change in weight is still usually fluid
 The woman should have a careful weekly examination to look for signs of fluid overload.
With daily dialysis, volume-related hypertension should be minimized, and if there is any
increase in blood pressure, particularly during dialysis, the patient should be evaluated
for preeclampsia.

29. 7.HEPARINIZATION
 Clotting of the extracorporeal circuit or the dialysis
access occurs frequently during pregnancy.
Heparin does not cross the placenta, and unless
there is vaginal bleeding, it is not necessary to
lower the dose

30. Thank you