Pregnancy in Pre-Existing Kidney Disease

1. Mohammed Abdel Gawad
Nephrology Specialist
Kidney & Urology Center (KUC) – Alexandria
drgawad@gmail.com
Pregnancy in Pre-Existing
Kidney Diseaseh
Prenatal Nephrology Care
h
Dialysis Regimen & Precautions

2. Pregnancy in Pre-Existing
Kidney Disease
CKD ND CKD 5D

3. Is pregnancy with pre-existing kidney
disease is a common problem?
What is the frequency or incidence of
conception & pregnancy in a woman
with pre-existing kidney disease?

4. Is Pregnancy with ESRD is a
Common Problem?
Country
Years
Period
Number of
Patients on HD
% of
conception
per year
European Transplant &
Dialysis Association
(13 European countries)
(1)
1970-1980 13,000 <1%
USA (2) 1992-1995
6230 women
(age14-44)
0.5%
Belgium (3) 1989 -1996 4,545 0.3%
Japan (4) 1977-1996
38,889
(age 32.7 ± 5.0)
3.4%
(1) Br J Obstet Gynaecol.1980;87(10):839-845.
(2) Okundaye I et al. Am J Kidney Dis. 1998;31(5):766-773.
(3) Jacques A et al. Am J Kidney Dis. Vol 31, No 5 (May), 1998
(4) Toma H et al. 1999;14(6): 1511-1516.

5. Is Pregnancy with ESRD is a
Common Problem?
Plant L et al. Renal disease in pregnancy. London: RCOG Press; 2008:272.
1 in 200 women of childbearing age
on dialysis become pregnant

6. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Contraception
in Childbearing Age
General Principles of
Prenatal Care
CKD ND CKD 5D
When to dialyse? Dialysis Regimen & Precautions
When to Terminate
Pregnancy
Normal Physiology during pregnancy
Talk
Outline

7. Normal Physiology during pregnancy
Talk
Outline

8. J Prakash . Indian Journal of Nephrology, Vol. 22, No. 3, May-June, 2012
Normal Physiological Renal
Changes During Pregnancy

9. Reproductive dysfunction in uremic women
Normal Physiology during pregnancy
Talk
Outline

10. 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.
Matuszkiewicz-Rowinska Jet al. Nephrol Dial Transplant. 19(8):2074-2077, 2004
Low levels of
estrogen &
progesterone.
Actually, they do get pregnant !!

11. Reproductive dysfunction in uremic women
CKD Classification in Pregnancy
Normal Physiology during pregnancy
Talk
Outline

12. CKD Classification & GFR
Estimation in Pregnancy
None of the eGFR formulas is valid for
pregnancy.
S.Cr remains the standard for
assessment of renal function during
pregnancy.
Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
Which eGFR formula to use in
Pregnant CKD?

13. CKD Classification & GFR
Estimation in Pregnancy
CKD Classification in Pregnancy
Mild Moderate Sever
S.Cr
< 1.5 mg/dL
S.Cr
1.5-2.5 mg/dL
S.Cr
> 2.5 mg/dL
This classification based on the difference between these
category levels regarding:
1- CKD progression.
2- Maternal outcome.
3- Fetal outcome.
Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013

14. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Normal Physiology during pregnancy
Talk
Outline

15. CKD – Pregnancy
Relationship
Etiology (other than lupus nephritis) is probably not
a major determinant of worsening renal disease if
above factors are well controlled
- Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
- Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013

16. Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy
Outcome % in all
stages is highly
affected by level
of control of
hypertension

17. Jesudason S et al. Clin J Am Soc Nephrol. 9: 143–149, 2014
Vázquez-Rodríguez JG. Cir; 78: 99–102, 2010
Outcomes in mild & moderate stages are highly
affected by level of control of hypertension
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy

18. CKD – Pregnancy Relationship
Effect of Pregnancy on CKD
Renal Outcome
Mild
S. Cr < 1.5
g/dl
<10% → decline in renal function
Moderate
S.Cr 1.5-3
g/dl
30 % → GFR decline in 3rd
trimester or
early postpartum
Risk of an irreversible loss of GFR
> 50 % if uncontrolled hypertension
10% → progresses to ESRD within
6-12 months after delivery.
Sever
S.Cr > 3
g/dl
Progression to ESRD is high.
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
Outcome % in all
stages is highly
affected by level
of control of
hypertension

19. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Normal Physiology during pregnancy
Talk
Outline

20. Pre-Pregnancy
Counseling in CKD
Discuss with the patient the possible
adverse events which may arise during or
as a consequence of her pregnancy
Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015

21. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Normal Physiology during pregnancy
Talk
Outline
General Principles of
Prenatal Care

22. Multidisciplinary Team
ObstetricianNephrologist
NeonatologistNutritionist
The Patient
The Patient
Family

23. 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

24. 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
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Reddy SS, Holley JL. Adv Chronic Kidney Disease; 14:146–155, 2007
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

25. 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

26. 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

27. 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
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015

28. 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
- Khalafallah AA et al. BMJ Open. 2(5). pii:e000998, 2012
- BaruaM et al. Clin JAmSoc Nephrol. 3(2):392-396, 2008.
ESAs at doses higher than
needed before pregnancy
(Doubling of the baseline EPO
requirements is not infrequent)
Intravenous iron as required
General Principles of
Prenatal Care & Management

29. 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
- Khalafallah AA et al. BMJ Open. 2(5). pii:e000998, 2012
- BaruaM et al. Clin JAmSoc Nephrol. 3(2):392-396, 2008.
General Principles of
Prenatal Care & Management

30. 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
Stover J. Adv Chronic Kidney Dis. 14(2):212-214, 2007
General Principles of
Prenatal Care & Management

31. 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
Askie LM et al. Lancet. 369(9575):1791-1798, 2007.
General Principles of
Prenatal Care & Management

32. 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
Askie LM et al. Lancet. 369(9575):1791-1798, 2007.
The aim of aspirin is for the prevention of preeclampsia or
perinatal death
General Principles of
Prenatal Care & Management

33. 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
Heparin
Protein Diet
Identification and management of
urinary tract infection
Assessment of fetal well-being
Identification of superimposed
preeclampsia
Askie LM et al. Lancet. 369(9575):1791-1798, 2007.
General Principles of
Prenatal Care & Management

34. 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
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet
urinary tract infection
Assessment of fetal well-being
superimposed preeclampsia
Davison JM, Nelson-Piercy C, Kehoe S, Baker P, eds. Renal disease in pregnancy. London: RCOG Press; 2008:21-30
General Principles of
Prenatal Care & Management

35. 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
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet
urinary tract infection
Assessment of fetal well-being
superimposed preeclampsia
General Principles of
Prenatal Care & Management

36. Protein diet
Pregnant females are
counseled to have high
protein intake.
even when the ideal protein intake
in normal pregnancy has not yet
been assessed.
Low-protein diet is an
important tool in the
management of CKD.
Piccoli GB et al. Nephrol Dial Transplant. 26(1):196-205. 2011.
Little is known about the risk and
benefits of LPD in pregnant CKD.
Supplementary of
20 g/day necessary
for correct
development of the
fetus
1 g/kg/day
related to a
sufficient
mother intake
Recommended
Protein Intake
Pregnant CKD

37. 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
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
urinary tract infection
Assessment of fetal well-being
superimposed preeclampsia
General Principles of
Prenatal Care & Management

38. 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
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being
superimposed preeclampsia
General Principles of
Prenatal Care & Management

39. 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
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being Regular Assessment
superimposed preeclampsia
General Principles of
Prenatal Care & Management

40. 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
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being Regular Assessment
Superimposed preeclampsia Difficult Challenge !!!
General Principles of
Prenatal Care & Management

41. 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
- Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
- Napolitano R et al. Prenat Diagn. 32(2):180-184, 2012.

42. Superimposed Preeclampsia
Diagnosis of superimposed preeclampsia in
CKD pregnant is difficult
- Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
- Napolitano R et al. Prenat Diagn. 32(2):180-184, 2012.
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).

43. Superimposed Preeclampsia

44. 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. 74(4):274-281, 2012.
PIGF
Placental
development
sFlt1
Endothelial
damage
New hope for diagnosis

45. Superimposed Preeclampsia
PE CKD
PIGF
(placental development)
Low Normal
sFlt1
(endothelial damage)
High Normal

46. 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
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being Regular Assessment
Superimposed preeclampsia Difficult Challenge !!!
General Principles of
Prenatal Care & Management

47. Reproductive dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Normal Physiology during pregnancy
Talk
Outline
General Principles of
Prenatal Care
CKD 5D
Dialysis Regimen & Precautions

48. Pregnant CKD 5D
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
Filter Flux & S.A. ??
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

49. Pregnant CKD 5D
Dialysis Prescription
Intensive HD: average dialysis time of
more than 20-24 hours per week
or
switching to long nightly dialysis
Target: Urea < 50 mg/dL
or even < 45 mg/dL
What is the Evidence?
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Nadeau-Fredette et al. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), pp 246-252, 2013.
Duration, Frequency
& Efficacy

50. Pregnant CKD 5D
Dialysis Prescription
Nocturnal dialysis program.
All women conceived during chronic NHD treatment after a
NHD vintage of 3 ± 2 years.
None of them had conceived during previous conventional HD.
Canada: Clin JAmSoc Nephrol. 2008;3(2):392-396.
Singapore: Int J Gynaecol Obstet. 2006;94(1):17-22.
Duration, Frequency
& Efficacy
France: Nephrologie. 2004;25(7):287-292.
Italy: Ren Fail. 2002;24(6):853-862.

51. Pregnant CKD 5D
Dialysis Prescription
Percentage of Living Infants
Spontaneous
Abortion
Neonatal&
InfantDeath
Preterm
Preterm
IUGR
IUGR
IUGR
Duration, Frequency
& Efficacy
Preterm
Preterm
Stillbirth
Canada: Clin JAmSoc Nephrol. 2008;3(2):392-396.
Singapore: Int J Gynaecol Obstet. 2006;94(1):17-22.
IUGR not reported
France: Nephrologie. 2004;25(7):287-292.
Italy: Ren Fail. 2002;24(6):853-862.

52. Pregnant CKD 5D
Dialysis Prescription
Percentage of Pre-eclampsia
Not Reported
Duration, Frequency
& Efficacy
Canada: Clin JAmSoc Nephrol. 2008;3(2):392-396.
Singapore: Int J Gynaecol Obstet. 2006;94(1):17-22.
France: Nephrologie. 2004;25(7):287-292.
Italy: Ren Fail. 2002;24(6):853-862.

53. Pregnant CKD 5D
Dialysis Prescription
Percentage of Polyhydraminos
Target Urea:
Duration, Frequency
& Efficacy
Canada: Clin JAmSoc Nephrol. 2008;3(2):392-396.
Singapore: Int J Gynaecol Obstet. 2006;94(1):17-22.
France: Nephrologie. 2004;25(7):287-292.
Italy: Ren Fail. 2002;24(6):853-862.

54. Pregnant CKD 5D
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

55. Pregnant CKD 5D
Dialysis Prescription
The potassium
concentration in dialysate
must also be adjusted to
reflect the more intensive
HD regimen,
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Nadeau-Fredette et al. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
usually with a
concentration of
3.0 mEq/L.
Dialysate K

56. Pregnant CKD 5D
Dialysis Prescription
↑ circulating progesterone
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Nadeau-Fredette et al. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), pp 246-252, 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

57. Pregnant CKD 5D
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
Tennankore KK et al.. Nat Rev Nephrol. 8(9):515-522, 2012.
Stop phosphate
binders
Dialysate P

58. Pregnant CKD 5D
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)
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
BaruaM et al. Clin JAmSoc Nephrol. 3(2):392-396, 2008
Take care of Hypercalcemia
Occasionally placental
production of vitamin D–like substances and PTHrP
Dialysate Ca

59. Pregnant CKD 5D
Dialysis Prescription
Vit D
Occasionally placental
production of vitamin D–like substances and PTHrP

60. Pregnant CKD 5D
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. Pregnant CKD 5D
Dialysis Prescription
Dialysate Na
J Prakash . Indian Journal of Nephrology, Vol. 22, No. 3, May-June, 2012
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Reduction in serum sodium during pregnancy
necessitates a concomitant reduction in dialysate
sodium concentration to around 135 mmol/l.

62. Pregnant CKD 5D
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

63. Pregnant CKD 5D
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)
Piccoli GB et al. Clin J Am Soc Nephrol. 5(1):62, 2010.
Smith WT et al. Int Urol Nephrol. 37(1): 145–51, 2005.
Heparinization should be
minimal to prevent
obstetric bleeding.
It is safe to use heparin whenever there is no vaginal
bleeding.
Heparnization

64. Pregnant CKD 5D
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

65. Pregnant CKD 5D
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. Pregnant CKD 5D
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
Filter Flux & S.A. ??
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. Pregnant CKD 5D
Dialysis Prescription
Filter Flux & S.A.
High flux

68. Pregnant CKD 5D
Dialysis Prescription High flux
Filter Flux & S.A.

69. Pregnant CKD 5D
Dialysis Prescription High flux
Filter Flux & S.A.

70. Pregnant CKD 5D
Dialysis Prescription Small S.A.
Filter Flux & S.A.

71. Pregnant CKD 5D
Dialysis Prescription Small S.A.
Filter Flux & S.A.

72. Pregnant CKD 5D
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
Filter Flux & S.A. High flux, Low S.A.
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. Pregnant CKD 5D
Dialysis Prescription
AVF
Cannulation
Risk for vascular access
dysfunction because of increased
frequency of dialysis
Avoided by rotating the needle
sites using rope ladder
technique

74. Pregnant CKD 5D
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
Filter Flux & S.A. High flux, Low S.A.
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

75. Pregnant CKD 5D
Dialysis Prescription
Dialysis in left lateral
decubitus position
Dialysis
Decubitus
St George Hospital, Renal Department Guidelines for Pregnancy & Dialysis,
2013.
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015

76. Pregnant CKD 5D
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
Filter Flux & S.A. High flux, Low S.A.
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. Pregnant CKD 5D
Dialysis Prescription
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Stover J. Adv Chronic Kidney Dis. 14(2):212-214, 2007.
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

78. Pregnant CKD 5D
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
Filter Flux & S.A. High flux, Low S.A.
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. Pregnant CKD 5D
Dialysis Prescription
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Careful uterine and fetal
monitoring during
hemodialysis
Assessment of the fetal
heart rate
(particularly during the last
portion of a session)
Fetal
Assessment

80. Pregnant CKD 5D
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
Filter Flux & S.A. High flux, Low S.A.
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. Pregnant CKD 5D
Dialysis Prescription
What is the importance of maintaining adequate
intravascular volume?
Avoid dialysis hypotension and
volume contraction which may
result in hemodynamic
compromise, reduced
uteroplacental perfusion, and
premature labor.
Preservation of GFR
and good pregnancy
outcome for mother
and baby
Piccoli GB et al. Clin J Am Soc Nephrol. 5(1):62, 2010.
UF & Dry weight
Assessment

82. Pregnant CKD 5D
Dialysis Prescription
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
UF & Dry weight
Assessment
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy

83. Pregnant CKD 5D
Dialysis Prescription
Blood pressure
out of target
Respiratory
compromiseClinical signs
of
hypervolemia
Edema is an
unhelpful sign in
pregnancy
Nadeau-Fredette et al. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), pp 246-252, 2013.
UF & Dry weight
Assessment
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy

84. Pregnant CKD 5D
Dialysis Prescription
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
UF & Dry weight
Assessment
How to assess intravascular volume in
pregnancy?
Tools to asses intravascular volume during
pregnancy

85. Pregnant CKD 5D
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
Filter Flux & S.A. High flux, Low S.A.
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

86. Normal Physiological Renal Changes during Pregnancy
Reproductive and sexual dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
General Principles of
Antenatal Care & Management
CKD ND CKD 5D
When to dialyse? Dialysis Regimen & Precautions

87. It is generally recommended to commence
dialysis at
eGFR 20 ml/min
Urea 50 mg/dl
S.Cr 3.5-5 mg/dl
- Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
- Asamiya Y et al. Kidney Int. 75;1217-1222, 2009.
Pregnant CKD ND
When to Initiate Dialysis?
Better outcomes of pregnancy. May reduce incidence of
polyhydramnios, lower urea and lowers water load, also
reducing risk of dialysis-induced hypotension.

88. Pregnant CKD ND
Dialysis?
Frequency & Duration ????

89. Pregnant CKD ND
When to Initiate Dialysis?

90. Normal Physiological Renal Changes during Pregnancy
Reproductive and sexual dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
General Principles of
Antenatal Care & Management
CKD ND CKD 5D
When to dialyse? Dialysis Regimen & Precautions
When to Terminate
Pregnancy

91. Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
When to Terminate
Pregnancy?

92. Normal Physiological Renal Changes during Pregnancy
Reproductive and sexual dysfunction in uremic women
CKD – Pregnancy Relationship
Effect of CKD on Pregnancy Effect of Pregnancy on CKD
CKD Classification in Pregnancy
Pre-Pregnancy Counseling in
CKD
Contraception
in Childbearing Age
General Principles of
Antenatal Care & Management
CKD ND CKD 5D
When to dialyse? Dialysis Regimen & Precautions
When to Terminate
Pregnancy

93. Contraception
Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013
Sexually active women who have normal periods
should use contraception if they do not wish to
become pregnant (esp if S.Cr > 3g/dl)
Although the frequency of conception in dialysis
patients is low
Contraception is advisable because of poor
pregnancy outcomes with advanced CKD
Complications of pregnancy are higher than
those of using oral contraceptives.

94. Contraception
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.
Kavitha Vellanki. Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013

95. Diagnosis of Pregnancy
in Dialysis Patients
Difficult to Diagnose !!

96. 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
Gianfranco Manisco et al. Clin Kidney J, 0: 1–7, 2015
Buckner CL et al. Ann Clin Lab Sci. 37(2):186-191, 2007.

97. Pregnancy in Dialysis
When? How many times?

98. 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.
Pregnancy in Dialysis
When? How many times?
Hou S. Am J Kidney Dis. 33(2):235, 1999.

99. Take Home Messages

100. CKD – Pregnancy
Relationship

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)
creatinine > 1.5 mg/dl
previous pregnancy complications
Heparin
Nephrotic Syndrome
Serum Albumin of <2.5 g/l
Protein Diet 1 g/kg/day + 20 g/day
Urinary tract infection
Early identification &
management
Assessment of fetal well-being Regular Assessment
Superimposed preeclampsia Difficult Challenge !!!
General Principles of
Prenatal Care & Management

102. 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
Filter Flux & S.A. High flux, Low S.A.
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

103. It is generally recommended to commence
dialysis at
eGFR 20 ml/min
Urea 50 mg/dl
S.Cr 3.5-5 mg/dl
Pregnant CKD ND
When to Initiate Dialysis?

104. Mark A. Brown. Comprehensive Clinical Nephrology. 5th
edition, chapter 45, 2015
When to Terminate
Pregnancy?

105. Pregnant CKD ND
When to Initiate Dialysis?

106. Contraception
Sexually active women who have normal periods
should use contraception if they do not wish to
become pregnant (esp if S.Cr > 3g/dl)
Contraception is advisable because of poor
pregnancy outcomes with advanced CKD

107. Diagnosis of Pregnancy
in Dialysis Patients
Challenging
USS

108. Diagnosis of Pre-
eclampsia of
Pregnancy in Dialysis
Patients
Challenging
Hope – New Markers

109. Gawad
Thank You