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Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadNephroTube - Dr.Gawad
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- English version of this lecture is available at:
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Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
- English version of this lecture is available at:
https://youtu.be/XRD-QqGFP18
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Diabetes Mellitus Management in CKD (Clinical Tips) - Dr. GawadNephroTube - Dr.Gawad
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Presentation given to our fellowship program about diabetic kidney disease.
2022 update discussing SGLT2i, MRA (e.g. finerenone), health economics and beyond
Steroid Sparing Regimens in Kidney TransplantationAbdullah Ansari
Mechanisms of action of steroids
Rationale for steroids minimization
Steroid minimization strategies
Very low maintenance dosages
Complete withdrawal early after transplantation (three to six months post-surgery)
Complete withdrawal later after transplantation (six months to one year post-surgery)
Steroid free maintenance, after rapid withdrawal within a week
Complete avoidance
- English version of this lecture is available at:
https://youtu.be/XRD-QqGFP18
- Arabic version of this lecture is available at:
https://youtu.be/c9PoavAtNKM
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- A new version of this lecture is available at: https://www.slideshare.net/MohammedGawad/thrombotic-microangiopathy-tma-in-adults-and-acute-kidney-injury-dr-gawad
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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
Ovarian Hyperstimulation Syndrome(OHSS), is a Rare iatrogenic complication of ovarian stimulation occurring during the luteal phase or during early pregnancy where a patient's ovaries become swollen and fluid builds up around her abdomen
IVF Pregnancy -Is it different? A presentation by Dr Laxmi Shrikhande the leading IVF specialist in India
IVF (In Vitro Fertilization) pregnancy can be both similar to and different from natural conception in several ways. In IVF, fertilization of the egg occurs outside the body in a laboratory setting, typically involving the extraction of eggs from the ovaries and combining them with sperm in a petri dish. Once fertilization is successful, the resulting embryos are transferred to the uterus for implantation
Intrahepatic Cholestasis of Pregnancy - Prof Surekha TayadeSurekhaTayade4
This presentation is for undergraduates, postgraduates, consultants and nurses and describes incidence, etiology, pathophysiology, complications and management of intrahepatic cholestasis of pregnancy /obstetric cholestasis
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
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- Video recording of this lecture in English language: https://www.youtube.com/watch?v=MA7nU5NWL2g&list=PLL7Q08IoVDSpg0VlGdvCHOHbXqMs0GFRe
- Video recording of this lecture in Arabic language: https://www.youtube.com/watch?v=FiWabzTPFqY&list=PLL7Q08IoVDSrVcm6SmppQyefL_Ub2-xGY
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Thrombotic Microangiopathy (TMA) in Adults and Acute Kidney Injury - Dr. GawadNephroTube - Dr.Gawad
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- English version of this lecture is available at:
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- English version of this lecture is available at:
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Infection-related Glomerulonephritis (KDIGO 2021 Guidelines) - Dr. GawadNephroTube - Dr.Gawad
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- English version video of this lecture is available at:
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- English version of this lecture is available at: https://youtu.be/_Efu52kZRS4
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- English version of this lecture is available at: https://youtu.be/WHu05hmExBY
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Insights from the FIGARO-DKD and FIDELIO-DKD trials - Dr. GawadNephroTube - Dr.Gawad
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Pregnancy in End Stage Renal Disease Patients - Dr. Gawad
1. Pregnancy in End Stage
Renal Disease Patients
Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC)
Alexandria – EGY
drgawad@gmail.com
Mansoura MD Program – 25, Jul, 2016
2. To get the presentation with full animations
please contact me on
drgawad@gmail.com
For more presentations visit
www.NephroTubeCNE.com
3. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
4. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
5. Reproductive and sexual
dysfunction in uremic women
Dysregulation of the menstrual cycle, leading to
amenorrhea by the time the patient reaches ESRD.
Anovulation, even
with preserved
menstrual cycles.
LH surge Absent.
Abnormalities in
endometrial
morphology
Decreased kidney prolactin
clearance in advanced CKD.
Kidney Int. 2016 May;89(5):995-1007
Hemodialysis International 2016; 20:339–348
Low levels of
estrogen &
progesterone.
6. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Reproductive and sexual
dysfunction in uremic women
Dysregulation of the menstrual cycle, leading to
amenorrhea by the time the patient reaches ESRD.
Anovulation, even
with preserved
menstrual cycles.
LH surge Absent.
Abnormalities in
endometrial
morphology
Decreased kidney prolactin
clearance in advanced CKD.
Kidney Int. 2016 May;89(5):995-1007
Hemodialysis International 2016; 20:339–348
Low levels of
estrogen &
progesterone.
Actually, they do get pregnant !!
7. The incidence of pregnancy in women on
hemodialysis has been documented to
range from <1% to 7%
Kidney Int. 2016 May;89(5)
8. Nephrol Dial Transplant (2015) 0: 1–20
n=90 pregnancies from 2000 to 2008
n=616 pregnancies from 2000 to 2014
Clin J Am Soc Nephrol (2010) 5: 62–71
9. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
10. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
11. Br Med J. 2008;336:311-5.
Effect of Renal Function on Pregnancy
Outcomes
12. Hippokratia. 2011 Jan; 15 (Suppl 1): 8–12.
Effect of Renal Function on Pregnancy
Outcomes
13. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
14. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
16. Am J Kidney Dis. 2015 Dec;66(6):951-61
Pre-Pregnancy Counselling
17. Am J Kidney Dis. 2015 Dec;66(6):951-61
Pre-Pregnancy Counselling
18. Am J Kidney Dis. 2015 Dec;66(6):951-61
Pre-Pregnancy Counselling
19. ACKD Journal, Vol 20, No 3 (May), 2013
Complications of pregnancy are higher
than those of using oral contraceptives.
Pre-Pregnancy Counselling
Contraception
20. Oral contraceptives is safe in most dialysis patients, but
these drugs should be avoided in patients with lupus and
patients with problems of clotting vascular access.
Which Method to Use?
Intrauterine devices may be associated with increased
bleeding because of heparin use with hemodialysis.
Commonly used barrier methods of contraception are safe.
ACKD Journal, Vol 20, No 3 (May), 2013
Pre-Pregnancy Counselling
Contraception
21. Hemodialysis International 2016; 20:339–48
J Perinat Med. 2015.
Transplantation options should be
reviewed with women while they are on
dialysis, before attempting conception,
because of better pregnancy outcomes
Pre-Pregnancy Counselling
Transplantation Advice
22. Hemodialysis International 2016; 20:339–48
There are no data as yet on the safety or
effectiveness of assisted reproductive
technologies in this patient population
Pre-Pregnancy Counselling
Assisted reproductive
technologies??
23. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
24. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
26. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
27. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
28.
29. 36 h or more of HD weekly for
pregnant women with established
ESRD without residual renal
function
Hemodialysis International 2016; 20:339–348
44. Provision of intensified dialysis offers improved management
of uremic toxins and blood volume, which may decrease the
incidence of polyhydramnios and, as a result, decrease the
likelihood of premature delivery and its complications
J Ultrasound Med. 2013; 32:851–863.
Target: BUN ??
45. Target: BUN < 50 mg/dL
or even < 45 mg/dL
Hemodialysis International 2016; 20:339–348
49. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
50. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
51. Dialysis Prescription
The potassium
concentration in dialysate
must also be adjusted to
reflect the more intensive
HD regimen,
Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
usually with a
concentration of
3.0 mEq/L.
Dialysate K
52. Dialysis Prescription
↑ circulating progesterone
Kidney Int. 2016 May;89(5)
Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
Relative hyperventilation
Mild respiratory alkalosis
Subsequent reduction in
serum bicarbonate of
approximately
4 mEq/L
To ensure the physiologic
expression of respiratory alkalosis
that is associated with pregnancy,
dialysate bicarbonate usually
reduced to 25 mEq/L to maintain
serum bicarbonate in the usual
pregnancy range of 18 to 22
mmol/l
Normal Pregnancy Physiology
Dialysate Bicarbonate
53. Dialysis Prescription
Intensive dialysis and increased phosphate
requirements for fetal bone formation
Decrease S.Phosphate levels
(hypophosphatemia)
Phosphate levels need to be
monitored frequently
Supplement with
oral phosphate
increased dialysate
phosphate
Hemodialysis International 2016; 20:339–348
Nat Rev Nephrol. 2012;8(9):515-522.
Stop phosphate
binders
Dialysate P
54. Dialysis Prescription
Increase dialysate
calcium to 1.75 -
2.5 mmol/L
Predialysis and postdialysis calcium
levels should be measured to avoid
hyper- and hypocalcaemia
oral calcium
(1.5-2g/d)
Hemodialysis International 2016; 20:339–348
Clin JAmSoc Nephrol. 2008;3(2):392-396.
Take care of Hypercalcemia
Occasionally placental
production of vitamin D–like substances and PTHrP
Dialysate Ca
56. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
57. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
59. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Dialysate Na
Indian Journal of Nephrology, Vol. 22, No. 3, May-June, 2012
Reduction in serum sodium during pregnancy
necessitates a concomitant reduction in dialysate
sodium concentration to around 135 mmol/l.
60. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
61. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
62. Dialysis Prescription
Dialysis heparin
requirements are often
increased because
of the hypercoagulable
state of pregnancy
(this is not the situation for every
pregnant woman and is assessed by
monitoring dialysis adequacy and
dialyser clotting)
Hemodialysis International 2016; 20:339–348
Piccoli GB et al. Clin J Am Soc Nephrol. 2010;5(1):62.
Heparinization should be
minimal to prevent
obstetric bleeding.
Heparin is a safe and effective anticoagulation
therapy that prevents circuit clotting
Heparnization
63. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
64. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
65. Dialysis Prescription
At each HD session, blood
flow gradually increased over
1st 30 minutes of HD, from
180 to 300 ml/min
Blood Flow
66. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
67. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
73. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
74. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
76. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
77. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
79. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
80. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
81. Dialysis Prescription
Hemodialysis International 2016; 20:339–348
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
Minerals and
water soluble
vitamins
82. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
83. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
84. Fetal Assessment
Serial ultrasound examinations are
importantfor the early detection fetal
growth restriction
Assessment of the fetal
heart rate
(particularly during the last
portion of a session)
Kidney Int. 2016 May;89(5)
86. Fetal Assessment
J Matern Fetal Neonatal Med. 2016 Jul 12:1-16.
There may be no fetal benefit of EFM during HD for
gravid women with renal disease attributed to
hypertensive and diabetic nephropathy. There may
be cost savings by shifting HD to the outpatient
setting.
87. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
88. The 6th
International Hemodialysis Course, UNC, Mansoura University, Dec 23-7, 2013
Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
89. Body weight gain
1 to 2 kg during
the first three
months
Institute of Medicine and National Research Council. Weight Gain During
Pregnancy: Reexamining the Guidelines. The National Academies Collection:
Reports Funded by National Institutes of Health. Washington, DC: National
Academies Press; 2009.
then
0.5 kg a week
during the rest of
pregnancy
Normal body
weight gain
in pregnancy
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy
Dialysis Prescription
UF & Dry weight Assessment
90. Blood pressure
out of target
Respiratory
compromiseClinical signs
of
hypervolemia
Edema is an
unhelpful sign in
pregnancy
Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy
Dialysis Prescription
UF & Dry weight Assessment
91. Measure
Hematocrit &
Albumin at the
initial first-
trimester visit.
A rise in either
value strongly
suggests
intravascular
volume
contraction.
Hematocrit
& Albumin
levels
Opposite is not true
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy
Dialysis Prescription
UF & Dry weight Assessment
92. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >36h/w, Urea<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
93. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
94. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
95. General Principles of
Prenatal Care & Management
Problem How to manage?
Hypertension
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Urinary tract infection
Assessment of fetal well-being
Superimposed preeclampsia
96. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
This range of treatment is not based on solid
pregnancy outcome data
But is thought to be the range that reduces maternal
risk for severe hypertension while providing sufficient
systemic BP to maintain placental perfusion
General Principles of
Prenatal Care & Management
Hemodialysis International 2016; 20:339–348
97. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Ines et al. Clinical Medicine 2013, Vol 13, No 1: 57–62
General Principles of
Prenatal Care & Management
98. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Ines et al. Clinical Medicine 2013, Vol 13, No 1: 57–62
General Principles of
Prenatal Care & Management
99. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Take Care
Diuretics
may cause reduction in maternal plasma
volume, uteroplacental or renal perfusion.
General Principles of
Prenatal Care & Management
100. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Kidney Int. 2016 May;89(5)
Hemodialysis International 2016; 20:339–348
Khalafallah AA et al. BMJ Open. 2012;2(5).
ESAs at doses higher than needed before (Doubling
of the baseline EPO requirements is not infrequent)
Intravenous iron as required
(Currently, the US Food and Drug Administration
classifies only iron sucrose as a pregnancy category B
drug)
General Principles of
Prenatal Care & Management
101. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Kidney Int. 2016 May;89(5)
Adv Chronic Kidney Dis. 2007;14(2).
General Principles of
Prenatal Care & Management
102. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Use Low-dose aspirin (75-150 mg/day) if
if there is no obvious contraindication
serum creatinine above
1.5 mg/dl
If one of the following in a previous
pregnancy:
A- early-onset severe preeclampsia
B- fetal loss
General Principles of
Prenatal Care & Management
Ann Intern Med. 2014 May 20;160(10)
Kidney Int. 2016 May;89(5)
103. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
The aim of aspirin is for the prevention of preeclampsia or
perinatal death
General Principles of
Prenatal Care & Management
Ann Intern Med. 2014 May 20;160(10)
Kidney Int. 2016 May;89(5)
104. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
General Principles of
Prenatal Care & Management
105. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Superimposed preeclampsia
General Principles of
Prenatal Care & Management
106. Superimposed Preeclampsia
Diagnosis of superimposed preeclampsia in
CKD pregnant is difficult
Already patient has
renal impairment
± proteinuria
± the absence of significant
urine output if late stage
CKD or 5D
↑ BP, ↓ GFR, ↑ serum urate,
or ↑ protein excretion
can be due to progression the
renal disorder rather than
superimposed preeclampsia
Kidney Int. 2016 May;89(5)
Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
Prenat Diagn. 2012;32(2):180-184.
107. Superimposed Preeclampsia
Diagnosis of superimposed preeclampsia in
CKD pregnant is difficult
When to suspect pre-eclampsia?
after 20 weeks of pregnancy
Unexplained rise in BP not
responding to fluid removal & drugs
Development of classic
preeclampsia symptoms
(visual abnormalities, severe
headache, epigastric pain &
hyper-reflexia)
Laboratory abnormalities
consistent with the HELLP
syndrome & thrombocytopenia
Fetal growth restriction and
abnormal umbilical artery blood
flow (uterine artery doppler).
Kidney Int. 2016 May;89(5)
Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
109. Superimposed Preeclampsia
fms-like tyrosine kinase-1
(sFlt1), a placental
antiangiogenic factors to both
vascular endothelial growth
factor and placental growth
factor (PIGF)
Sharon E. Maynard et al. J Am Soc Nephrol 20: 14–22, 2009Levine RJ et al. Gynecol Obstet Invest. 2012;74(4):274-281.
PIGF
Placental
development
sFlt1
Endothelial
damage
New hope for diagnosis
112. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Superimposed preeclampsia Difficult Challenge !!!
General Principles of
Prenatal Care & Management
113. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
114. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
116. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
117. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
118. Diagnosis of Pregnancy
in Dialysis Patients
A high degree of suspicion is
required to make the diagnosis
of pregnancy
Difficult to Diagnose !!
Amenorrhea is frequent in CKD 5D
Nausea, vomiting, fatigue & soft
signs of pregnancy are often
attributed to the kidney condition,
volume overload & erythropoietin
deficiency.
Because beta HCG is removed by
the kidney, beta HCG levels are
higher at each stage of gestation
than in women with normal renal
function.
Borderline positive HCG levels can
be seen in nonpregnant CKD 5D.
The stage of gestation must
be determined by
ultrasound
Hemodialysis International 2016; 20:339–348
119. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
120. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
122. Repeat pregnancies in women who become pregnant on
dialysis are not uncommon.
(In the 318 women whose pregnancies are recorded by the National
Registry for Pregnancy in Dialysis Patients (NPDR), eight women
became pregnant twice, eight women became pregnant three times,
and one woman conceived four times.)
Most pregnancies occur during first few years on dialysis,
but conception rates as a function of time on dialysis have
not been determined.
Pregnancy has occurred in women who have
been on dialysis for as long as 20 years.
Hou S. Am J Kidney Dis. 1999;33(2):235.
123. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
124. Talk Outline
Sexual dysfunction / Incidence of pregnancy
Renal impairment effect on pregnancy
outcome
Pre-Pregnancy Counseling / Contraception
Dialysis prescription
General Care
When to terminate pregnancy
Pregnancy Diagnosis
Pregnancy in Dialysis, When? How many
times?
Lactation
131. Dialysis Prescription
Item How to deal with?
Duration, Frequency & Efficacy >24h/w, BUN<50
Dialysate K 3mEq/L
Dialysate Bicarbonate 25mEq/L
Ca, Pi & PTH balance Ca 1.75-2.5mmol/L,↑ dialysate P
Dialysate Na 135mEq/L
Heparnization heparin if no vaginal bleeding
Blood Flow Gradual increase
High vs Low flux ??
AVF Cannulation Rope Ladder
Dialysis Decubitus left lateral decubitus
Minerals and water soluble vitamins Increase Supplements
Fetal Assessment Every session, esp at the end of session
UF & Dry weight Assessment Assess regularly Big challenge
132. Problem How to manage?
Hypertension Target BP 110-140/80-90 mmHg
Anemia Maintain Hemoglobin 10–11 g/dl
Folic acid
for every pregnant woman
(5 mg daily if on dialysis)
Aspirin (75–150 mg/day)
creatinine > 1.5 mg/dl
previous pregnancy complications
Superimposed preeclampsia Difficult Challenge !!!
General Principles of
Prenatal Care & Management