This document discusses the management of pregnant women on hemodialysis. It notes that physiological changes during pregnancy can impact kidney function, but intensive hemodialysis of more than 20 hours per week is recommended to reduce risks. Close monitoring of blood pressure, nutrition, mineral levels, anemia and fetal growth is important. Hemodialysis prescription should be tailored to each patient's needs, with adjustments to dialysate composition and blood flow. Vaginal delivery at 38 weeks is typically recommended unless complications arise. A multidisciplinary team of nephrologists, obstetricians and dietitians helps optimize outcomes for these high-risk pregnancies.

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

2. Physiological changes in pregnancy

3. 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.

4. Anatomic changes during pregnancy
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.

5. Anatomic changes during pregnancy
 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.

6. 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.

7. Functional renal changes during pregnancy
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.

8. Functional renal changes during pregnancy
 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 .

9. Functional renal changes during 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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

15. 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.

16. 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.

17. Diagnosis of pregnancy in dialysis patients??

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

20. Management of dialysis pregnant lady

21. 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.

22. 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

23. 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).

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

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

26. Role of obstetrician
• 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.

27. Role of obstetrician
• 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.

28. 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

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

30. 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

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

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

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

34. Hemodialysis prescription
• 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

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

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

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

38. 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

39. Hemodialysis prescription
•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

40. Hemodialysis prescription
• 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.

41. Hemodialysis prescription
Dialysis in left lateral decubitus position

42. 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
- .

43. 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.

44. 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.

45. Management of pregnant women on hemodialysis