Nottingham University Hospitals February 1 st 2019 Pregnancy and dialysis Not being pregnant Pregnancy and haemodialysis Pregnancy and peritoneal dialysis Renal Association Guidelines on Pregnancy and Renal Disease a sneak peak ID: 1041425
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1. Dr Matt HallConsultant NephrologistNottingham University HospitalsFebruary 1st 2019
2. Pregnancy and dialysisNot being pregnantPregnancy and haemodialysisPregnancy and peritoneal dialysisRenal Association Guidelines on Pregnancy and Renal Disease (a sneak peak…)
3. If a patient receiving dialysis asks me about pregnancy, my approach is:What time does Mothercare shut? We can go together!It won’t be easy but we can look at options to give you the best chance of successIt is not safe to think about pregnancy until you’ve had a transplantPregnancy and kidney disease are a bad combination and you will not be able to start a family
4. Young adults with end stage renal diseaseWant to have children nowNever want to have childrenWant to have children later
5. Contraception and CKDEffectivenessSafetyThanks to Dr Kate Wiles
6. The best option for a 19 year old with advanced CKD who does not want to get pregnant is:AbstinenceCombined Oral Contraceptive PillCopper IUCDNexplanon progesterone implantSterilisation
7. Contraception and CKDPerfect useTypical useTrussell J. Contraception 2011, 83:379-404
8. Contraception and CKDRisksCOCP – hypertension, sodium retention, glomerular hyperfiltration, VTE risk (nephrotic?), arterial thrombosisProgesterone – decreased BMD?, dyslipidaemia?IUDs – increased risk of failure and infection in transplant recipientsGrandi G et al. Contraception 2014,90(5):529-534Pechere-Bertschi A, Maillard M et al. Kidney Int 2003,64(4):1374-1380Estes CM, Westhoff C. Semin Perinatol 2007,31(6):372-377Ramhendar T, Byrne P. Contraception 2012, 86(3):288-289
9. Contraception and CKDCerazetteCerelleAizeaNacrezMircera IUDNexplanon implantCopper IUDSterilizationPOPProgesterone>40 years?
10. Young adults with end stage renal diseaseWant to have children nowNever want to have childrenWant to have children laterWill I ever be able to have a baby?Wait for a renal transplant with good function and minimal immunosuppression and negligible hypertension
11. 17 year old.Renal agenesis2x previous transplantsHaemodialysis last 3 yearsHome HD for the last 12 months4 x 3hrs per weekPRA 100% inc anti-HLA A2 antibodiesNo live donors identifiedNot had regular periods since returning to dialysisWill I ever be able to have a baby?
12. Patients on dialysis are as likely to conceive as patients following renal translantationTrueFalse
13. Barua M, Hladunewich M, Keunun J et al. Clin J Am Soc Nephrol 2008;3:392/396Okundaye IB, Abrinko P, Hou S. Am J Kidney Dis 1998; 31(5):974-9810-20 hrs/week36-57 hrs/week?
14. Hall M. Am J Kidney Dis. 2016 Oct;68(4):633-9Davison J, Bailey DJ. J Obstet Gynaecol Res. 2003;29(4):277-233
15. HD and pregnancyCKD progression
16. p=0.03p=0.01HD and pregnancy
17. 2 x 12 hours HD /weekConceived January 1970Delivery at 39+4 weeks1950gConfortini P, Galanti G, Ancona G, Giongio A, Bruschi E, Lorenzini E: Full-term pregnancy and successful delivery in patient on chronic hemodialysis. Proc Eur Dial Transplant Assoc 8: 74–80, 1971 Pregnancy and dialysis
18. Pregnancy and HD1990 - 2013
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20. Is >37 hours/week necessary for all?Maintenance HD patient or starting in pregnancyPregnancy confirmed?6 x 1.5-2 hrs /week6 x 2-3 hrs /weekDiuresis>1000ml/d<1 year HDOr TW<70kgDiuresis<1000ml/d>1 year HDor TW>70kgSevere HypertensionAnorexia, nauseaExcessive weight gainPolyhydraminosPre-dialysis urea>12.5mmol/lIncrease session length by 30 minutes
21. Is >37 hours/week necessary for all?50.5% on dialysis prior to conceptionAverage dialysis time: 15.4 ±4.0 h/weekSuccessful delivery: 89.2%Mean fetal weight: 1689 ± 719gGestational age at delivery: 35 weeks (range 25-39)
22. Target weightIncrease by 1.5kg over first trimester0.2-0.4 kg/week from week 15Weekly clinical evaluationBlood pressureTarget blood pressure <140/90Do not treat to DBP<80mmHgAnaemiaESA requirement increases by 85% at 28 weeksTarget Hb 10-11g/dlNutritionProtein intake >1.8g/kg/dayEnergy intake 30kcal/kg/dayWater soluble vitamin and folic acid supplementation Fetal growth monitoring every 1 – 2 weeks Liquor volume monitoring every 1 – 2 weeks CTG monitoring every week from 25 weeksWrite a week-to-week care planFor example…
23. Renal Association GuidelinesDialysis and pregnancyWomen receiving maintenance dialysis before pregnancyGuideline x.x - We recommend that women established on dialysis planning a pregnancy should receive preconception counselling which includes the options of postponing pregnancy until transplantation (when feasible) and long frequent dialysis prior to and during pregnancy (Grade C)Guideline x.x - We recommend that women established on haemodialysis prior to pregnancy should receive long, frequent haemodialysis either in-centre or at home to improve pregnancy outcomes (Grade C)Guideline x.x - We recommend that women receiving haemodialysis during pregnancy should have dialysis dose prescribed accounting for residual renal function, aiming for a pre-dialysis urea <12.5mmol/l (Grade C)
24. Dialysis and pregnancyCKD progressionINTENSEHDSupplemental HD
25. When do you need to start dialysis in pregnancy?“Standard” AKI/CKD indicationsSigns of fetal compromiseUrea > 15mmol/l?20mmol/l??
26. Renal Association GuidelinesDialysis and pregnancyInitiating dialysis during pregnancyGuideline x.x - We recommend that haemodialysis should be initiated in pregnancy when the maternal urea concentration is 17-20mmol/L and the risks of preterm delivery outweigh those of dialysis initiation. Gestation, renal function trajectory, fluid balance, biochemistry, and blood pressure control should be considered in addition to maternal urea concentration. (Grade D)
27. Maternal baseline urea >20mmol/lFetal survival – 0%p=0.03p=0.01Mackay EV. Aust N Z J Obset Gynecol 1963;3:21n=61950-19601995-2010
28. Renal Association GuidelinesThe guideline committee acknowledge that there are inadequate data to produce evidence-based recommendations on commencing dialysis during pregnancy. However strong support from the UK renal community was received, requesting expert opinion-based practice…
29. 3. Pregnancy, renal transplantation and dialysisPD and pregnancy…really?
30. What is your approach to a PD recipient who wants to get pregnant (transplant’s off the cards)?You can’t conceive if you’re on PD as the eggs get washed out in PD fluidI’ve looked after plenty of women on PD through pregnancy. You’ll be fine.PD might not be enough and you might have to switch to HD if you conceivePD won’t be adequate during pregnancy and we should switch to HD now
31. 1743Christopher Warwick instilled Bristol water and claret wine into a patient’s peritoneum through a leather pipe.G Wegner observed electrolyte and fluid transport across peritoneal membrane.18771918Cunningham and Blackfan used the peritoneal membrane as a route to fluid administration in severely dehydrated infants.1923Georg Ganter treated first patient with uraemia with intraperitoneal saline infusionsWear and team successfully used continuous PD for acute renal failure for the first time.19361964Boen develops automated peritoneal dialysis systemPalmer, then Weston and Roberts, then Henry Tenckhoff introduce the semi-permanent silicone catheter.1965-19671977-1979European units providing PD increased from 0 to 160ISPD founded19841992First EuroPD meeting1983First report of CAPD and pregnancy (Cattran)Oxford2018PD and pregnancy
32. PD and pregnancy104 patients in case reports and series
33. PD and pregnancySystematic reviewPublications 2000-2014616 pregnancies in women who received HD during pregnancy38 pregnancies in women who started PD before pregnancy27 started during pregnancy65%77%39%83%Piccoli GB, Minelli F, Versino E et al. NDT 2016;31:1915N/A48-88%Publication bias!
34. PD and pregnancy – practical issuesKids get in the way of everything…
35. PD and pregnancy – practical issuesInadequate clearance or UFDelivery (if approaching term)Switch to HDSupplement PD with HD
36. PD and pregnancy – practical issues4 x 2l over 9h4 x 2l over 9h3 x 2l manual exchanges9 weeks4 x 2l over 9h4 x 2l manual exchanges12 weeks4 x 2l over 9h5 x 3h/week HD19 weeks4 x 2l over 9h5 x 4h/week HD24 weeks4 x 2l over 9h5 x 4.5h/week HD28 weeks3 x 2l manual exchanges x2/weekDelivery at 37+6 weeks3.005kgElective LSCS Ross LE, Swift PA, Newbold SM et al. PDI 2016;36(5):575
37. PD and pregnancy - deliverySkinAnterior rectus sheathPeritoneal membraneSubcutaneous tissueUterine cavityUterine wallPeritoneal cavityMethod
38. Renal Association GuidelinesGuideline x.x - We recommend that women established on peritoneal dialysis prior to pregnancy should transition to haemodialysis during pregnancy (Grade D)
39. PD and pregnancyBetter pregnancy outcomes with end stage renal disease reported with:Renal transplant, thenHaemodialysisContinuation of pregnancy on PD not recommended but could be considered if:Good residual renal functionVascular or social barriers to HD
40. SummaryAlmost all women with CKD can consider a pregnancyThe role of a nephrologist is to describe the options, possible outcomes and risks……then support their decision through a pregnancy……and know your limits
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42. AcknowledgementsNottingham City HospitalDr Al FerraroDr Suzanne WallaceUK-CORDProf Sue CarrProf Nigel BrunskillProf Liz LightstoneDr Graham LipkinDr Clara DayDr Sajeda YoussoufPregnancy and CKD RDGPatient RepresentativesMs Gemma HaskeyMr Dennis CraneMs Tess HarrisDr Nadia Sarween Dr Kate BramhamDr Phil WebsterDr Kate Wiles Dr Ellen Cox Prof Cathy Nelson-PiercyDr Joyce Popoola Dr Jason WaughProfessor David EdwardsMrs Floria ChengMrs Andrea GoodlifeMrs Sue Shaw