Dialisi in Gravidanza

ANTE 2015
XXIII Corso Nazionale di Aggiornamento
Le 3 P … in Dialisi: Performace, Praticità
Professionalità
Riccione, 20 - 22 aprile 2015
Dialisi in Gravidanza
Giuseppe Gernone M.D.
SSVD di Nefrologia e Dialisi
Ospedale Santa Maria degli Angeli - Putignano
La Gravidanza nella
paziente uremica in
dialisi
First report
Full term pregnancy and successful
delivery in a patient in chronic
hemodialysis.
Confortini P, Galanti G, Ancona G, et al: Proc
EDTA 1971; 18:74-78
Nefrologia Putignano
Since the first reports, in the early
seventies, to the end of the millennium,
pregnancy on dialysis has been
considered an exceptional occurrence,
alternatively regarded as a miracle or as
an event to discourage for the maternal
and foetal risks.
Hou S. Adv Chronic Kidney Dis. 2007 Apr;14(2):116-8.
Holley JL, Reddy SS. Semin Dial. 2003 Sep-Oct;16(5):384-8.
Hou S. Am J Kidney Dis. 2010 Jul;56(1):5-6.
The panorama of the new millennium is somehow different:
-There
is a diffusion
of dialysis
in non
different
Countries,
to
Diffusione
della dialisi
in paesi
occidentali,
che respect
hanno un
thedifferente
Western Countries,
with nei
different
attitudes
towards e forte
atteggiamento
confronti
della gravidanza
pregnancy
and a strong
towards
large families and
spinta culturale
verso cultural
famigliedrive
numerose
contestualmente
ad
a lower
influence
on social
life "malattie
by “invisible
diseases”,
such
as
una minore
influenza
delle
invisibili”
come
l’ESRD
ESRD.
sulla vita sociale.
-This
of a large ad
series
of dialysis
patients
undergoing
Ciòlead
ha consentito
un gran
numero
di pazienti,
sottoposte a
successful
thus leading
to a more
positive
dialisi, dipregnancies,
condurre a termine
gravidanze
portando
così ad un
approach
to pregnancy
dialysis
approccio
più positivoinverso
la gravidanza in dialisi
Piccoli GB et al. Clin J Am Soc Nephrol. 2010 Jan;5(1):62-71.
Bahadi A et al. Saudi J Kidney Dis Transpl. 2010 Jul;21(4):646-51.
Chou CY et al. Eur J Obstet Gynecol Reprod Biol. 2008 Feb;136(2):165-70.
Malik GH et al. J Assoc Physicians India. 2005 Nov;53:937-41.
- There
animpressionante
impressive increase
in dialysis
C’è
statoisun
aumento
dell'efficienza
efficiency
allowed by
conventional
dialitica
consentita
da“intensive”
trattamentinon
"intensivi"
non
schedules (mainly
long-hours
nightly
dialysis)
convenzionali
(soprattutto
dialisi
notturna)
che ha
Thus allowed
attaining unmet
pregnancies
permesso
il raggiungimento
di results
risultatiininattesi
nelle
on dialysis, in dialisi.
gravidanze
Hladunewich MA et al. J Am Soc Nephrol. 2014 May;25(5):1103-9.
Barua M. et al Clin J Am Soc Nephrol. 2008 Mar;3(2):392-6.
- A trendtendenza
to empower
the patients, changing
Crescente
a responsabilizzare
i pazienti.
attitude towards
decisions
once
->the
Conseguente
differente
atteggiamento
verso
“contraindicated”
and may be one of the
decisioni
una volta "controindicate”.
for delle
an increase
in pregnancy
on in
->reasons
Aumento
gravidanze
nelle pazienti
dialysis
the western
world.
dialisi
nel in
mondo
occidentale.
Small N et al. BMC Health Serv Res. 2013 Jul 8;13:263.
Frequency of conception in dialysis
patients
Pregnancy remains uncommon in dialysis patients. Hou S:
Modification of dialysis regimens for pregnancy. Int J artif Organs 2002; 25 (9): 823-6
The reported frequency ranges from 0.3 to 1.5 % per
year. P. August, J. Vella: Pregnancy in women with underlying renal disease. Up to date
Nov. 2014
Nefrologia Putignano
Avere un bambino
inadialisi
èwhile
raro,
madialysis
non impossibile,
se la mortalità
Conclusions.
Having
baby
is rare
but anche
not
In altri
termini,
leon
probabilità
di avere
un impossible,
rimane early
alta. Una
'scalaremains
di in
probabilità'
stima
che
le100
donne
in dialisi hanno una
though
mortality
high.
There
is
a1:
‘scale
of probability’
bambino
dialisi
sono
circa
probabilità that
10 volte
minore
di averehave
un bambino
vivo rispetto a coloro
estimating
women
on dialysis
a 10-foldnato
rispetto
alla popolazione
italianalower
dellaprobability of
che sono state
sottoposte
trapianto
rene,
che
a loro volta
hanno una
delivering
a live-born
baby athan
those di
who
have
undergone
renal
stessa
fascia
di
età,
e
circa
1:10
rispetto
probabilità 10 volte
avere
un neonato
allaof
restante
transplantation,
who minore
in turn di
have
a 10-fold
lower rispetto
probability
delivering a
allecompared
donne con
dipopulation.
rene.
popolazione.
live-born
baby as
withtrapianto
the overall
Reasons for the rarity of Pregnancy (P) in
dialysis (D) patients
10% to 42% of women D patients of childbearing age are
menstruated
Perez RJ, et al: Obstet Gynecol 51:552-555, 1978
Holley JL, et al: Am J Kidney Dis29:685-690, 1997
Dialysis patients who menstruated were usually anovulatory
Lim VS, et al: Ann Intern Med 93:21-27; 1980
70% to 90% of the women are hyperprolactinemic
Lim VS, et al J Clin Endocrinol Metab 48:101-107; 1979
Most pregnancy occur during the first few years on D
P occurred in women who have been on D for as long as 20 yrs
Repeated P in women on D are not uncommon
Hou S. Am J Kidney Dis 33: 235-252; 1999
Nefrologia Putignano
Pregnancy outcome prior or after
starting dialysis
Conceived prior to Dialysis
Stillbirths
Spontaneous
Spontaneous
1.8%
Abortion
Abortion
1st trimester
2nd trimester 7%
7%
Conceived after starting Dialysis
Spontaneous
Abortion
Neonatal Deaths
Still Pregnant
5.3%
5,2%
1st trimester
25%
Spontaneous
Abortion
2nd trimester
16.8%
Therapeutic
abortion*
2.1%
Survivng Infants
Surviving Infants
* Only for medical complications
73.6%
Still Pregnant
1.6%
Stillbirths
8.1%
Neonatal Deaths
8.2%
Okundaye I: Registry of Pregnancy in dialysis patients. Am J Kidney Dis 31: 1998; 766-773
40.2%
Nefrologia Putignano
Pregnancy outcome versus number
of years on dialysis
60
Pregnancies
50
Surviving Infants
n° 40
30
57.4%
39.6%
20
10
38.4%
0%
0
< 1yr
1-5 yrs
>5-10 yrs
>10 yrs
Okundaye I: Registry of Pregnancy in dialysis patients. Am J Kidney Dis 31: 1998; 766-773
Nefrologia Putignano
Pregnancy outcome: HD vs PD
Okundaye I: Registry of Pregnancy in dialysis patients. Am J Kidney Dis 31: 1998; 766-773
40
35
HD
39,5
PD
37
30
25
%
22,8 22,8
22,8
20
13,8
15
9,3
10
6,7
5
2
2,9
2,8
5,7
2
0
Spontaneous
Spontaneous
Therapeutic
Abortion 1st
Abortion 2nd
Abortion*
Trimester
Trimester
* Only for medical complications
Still Pregnant
Surviving
Neonatal
Infants
Death
Stillbirths
Nefrologia Putignano
There was no significant era, disease,
race effect on LB rates.
or
Patients
onsottoposte
peritoneal
dialysis
were less
likely
to achieve
Le pazienti
a dialisi
peritoneale
hanno
minori
probabilitàa di
ottenere unacompared
gravidanza with
rispetto
a quelle in emodialisi
(P <0,02).
pregnancy
haemodialysis
patients
(P < 0.02).
Conception occurs in peritoneal
dialysis at slightly less than half the
rate of its occurrence in
hemodialysis patients
Hou S. PDI Vol. 21 (2001), Supplement 3: 290 - 94
Nefrologia Putignano
Reason for the difference in frequency of
conception between HD and PD patients
• Intraperitoneal fluid may cause mechanical interference
with transport of the ovulum to the fallopian tubes;
• Recurrent peritonitis may lead to tubal obstruction
• Hypertonic destrose damages the ovulum
Hou S. PDI Vol. 21 (2001), Supplement 3: 290 – 94
Reddy SS et al. Adv Chronic Kidney Dis. 2007 Apr;14(2):146-55.
Dimitriadis CA et al. Adv Perit Dial. 2011;27:101-5.
Nefrologia Putignano
Il
minor
numero
di of
casi
in PD
è almeno
riflesso
della
The
lower
number
cases
reported
on in
PDparte
is at un
least
in part
a
minore
prevalenza
di questa
Tuttavia,
base dei dati
reflection
of the overall
lowertecnica.
prevalence
of thissulla
technique.
dell’emodialisi
chelight
suggeriscono
stretto legame dialysis
tra risultati
However, on the
of the datauno
on extracorporeal
favorevoli
efficienza
dialitica, favourable
dev’ essereoutcomes
presa in and dialysis
suggestinged
a strict
link between
considerazione
la possibilità
un effetto
negativo
una
efficiency, the possibility
of adinegative
effect
of thelegato
lower ad
dialysis
minore
della
metodica.
efficiencyefficienza
should be
taken
into account.
Hladunewich MA et al. J Am Soc Nephrol. 2014 May;25(5):1103-9.
Barua M e al. Clin J Am Soc Nephrol. 2008 Mar;3(2):392-6.
TIMING OF START OF DIALYSIS IN
PREGNANCY
InitiateRRT
RRTquando
when al’equilibrio
good metabolic
fluid balance
cannot be
1)1)Iniziare
idrico eand
metabolico
non possono
achieved
by conservative
treatment (main
indication)
(not
essere
mantenuti
col solo trattamento
conservativo
(main
indication)
Nesrallah GE et al. CMAJ. 2014 Feb 4;186(2):112-7. doi: 10.1503/cmaj.130363.
graded).
(not
graded).
Tattersall J et al. Nephrol Dial Transplant. 2011 Jul;26(7):2082-6.
2) Considerare
In the decision
of starting
RRT,
consideril the
general
clinical context,
2)
il contesto
clinico
generale,
trend
di laboratorio
ed il
the trends
of ipertensione,
laboratory tests,
the control
hypertension
controllo
dell’
piuttosto
che il of
solo
valore dellaand fluid
overload, (not
rather
than creatinine-based thresholds alone (not graded)
creatinina
graded)
3) Considerare
Consider Urea
level indell’Urea.
the decision
on in
dialysis
BUN is un
3)
il livello
l’Urea
dialisistart:
è considerata
The cases
reported
in the
literature
rangewith
fromoutcomes
“early” when
considered
a
very
important
marker
associated
indicatore importante associato all’outcome. Tuttavia nessun
dialysis
start,started.
at a GFR
ofthreshold
about 20has
mL/min
to
a later start,
in
dialysis
is
already
No
been
described
for
valorekeeping
soglia èwith
stato
associato
all'avvio
della dialisi (not graded)
the
most
recent
guidelines
dialysis start (not graded)
4) Consider
Considerare
la
fase
gravidanza:
rischifrom
e benefici
4)
the
All phase
the
available
ofdella
pregnancy
data onindialysis
thebilanciare
decision,
start come
balancing
the risks
dell’avvio
dialisi start
versus
l’anticipazione
del in
parto
la 28a
and
benefitdella
observational
of dialysis
studies
versus
and
early
maydelivery
indirectly
late
be in(dopo
pregnancy
th
e ancor
dopo
34a specifically,
settimana
gestazionale)
graded).
(after
thepiù
28
favour
and,
oflamore
early
start of RRT
after
in pregnancy
the 34th (not
gestational
week)
AC et al.
Adv Chronic
Kidney
2013 May;20(3):246-52.
Piccoli
GB, Cabiddu
G, Castellino S, Gernone Nadeau-Fredette
G et al. A Best Practice
position
statement
on Dis.
Pregnancy
on Dialysis: The
(not
graded).
Jesudason S et al. Clin J Am Soc Nephrol. 2014 Jan;9(1):143-9.
Italian Study Group on Kidney and Pregnancy. JOURNAL
OF
NEPHROLOGY. IN
PRESS
Nefrologia Putignano
HEMODIALYSIS OR PERITONEAL DIALYSIS IN PREGANCY
1.
patients
already
dialysis
at conception,
dialysis can la
1. In
Nelle
pazienti
già inon
dialisi
al momento
del concepimento,
be
continued
with continuata
the same modality,
provided
that good
dialisi
può essere
con la stessa
modalità,
a
dialysis
efficiency
reached (evidence
scattered
condizione
che si is
raggiunga
una buonaform
efficienza
dialitica
reports).
(not graded).
2.
patients
who
need
to start
dialysis
in pregnancy
2. In
Nelle
pazienti
che
hanno
bisogno
di iniziare
la dialisiconsider
in
patient’s
preference,
phase
pregnancy,
expected
dialysis
gravidanza
considerare
le of
preferenze
della
paziente,
efficiency,
availability
of intensive
extracorporeal
dialysis and
l’epoca della
gravidanza,
l’efficienza
dialitica, la disponibilità
risk
of rapid
loss of kidney
function
graded).
di dialisi
extracorporea
intensiva
ed (not
il rischio
di una rapida
perdita della funzione renale (not graded).
No study specifically compared peritoneal dialysis (PD)
and extracorporeal dialysis (HD) in pregnancy. There are
reports of pregnancies on both dialysis modalities
Piccoli GB, Cabiddu G, Castellino S, Gernone G et al. A Best Practice position
statement on Pregnancy on Dialysis: The Italian Study Group on Kidney and
Pregnancy. JOURNAL OF NEPHROLOGY. IN PRESS
Amount of dialysis required
It
has been
common
practice latodose
increase
the
E ‘pratica
comune
aumentare
dialitica
amount
given to
womensolo
but
duranteofladialysis
gravidanza,
maacipregnant
sono ancora
there
guidelines
for quantità
the amount
of
poche are
lineefew
guida
relative alla
di
dialysis
needed.
dialisi necessaria.
Hou S: Modification of dialysis regimens for pregnancy. Int J artif Organs 2002; 25 (9): 823-6
Nefrologia Putignano
Pregnancy outcome versus intensity
of dialysis
30
25
20
Unsuccessful
Successful
15
10
75 %
5
44 %
33 %
9 - 14
15 - 19
Infant survival did not improve
until dialysis was increased to 20
hours per week or more.
0
20 - 30
Hou S: Modification of dialysis regimens for pregnancy.
Int J artif Organs 2002; 25 (9): 823-6
Nefrologia Putignano
DIALYSIS SCHEDULE ON HEMODIALYSIS
1. Hemodialysis is the standard extracorporeal treatment in
pregnancy; data on hemodiafiltration are few, suggesting equal
benefits (not graded).
From
Da unapunto
theoretical
diintensity
vista
point
teorico
of view,
l’emodiafiltrazione
hemodiafiltration
may
essere
be
più adatta
2. Haemodialysis
(frequency
and duration)può
should
bemore
suited
alla gravidanza,
to pregnancy,
datagiven
l’elevata
the tollerabilità
high
tolerance
e laand
migliore
the better
rimozione
removal
increased
in pregnancy
(strong
recommendation,).
of
delle
middle
medie
molecules
molecole.
allowed(6-7
by this
3. Quotidian
or
nightly
dialysis
daysmethod.
per week) should be offered
at least to patients withoutMmresidual
A et al. Lupus.
renal
2014 Apr
clearances.
4;23(9):945-948. [Epub
(strong
ahead of print]
Haase Met al. Nephrol Dial Transplant. 2005 Nov;20(11):2537-42.
recommendation).
4. Poiché
Since the
resultsdella
of pregnancy
improve
alongcon
thel'aumento
increase in
dialysis
i risultati
gravidanza
migliorano
delle
ore
hours,
statistical
significancestatistica
at or above
di
dialisireaching
raggiungendo
significatività
se ≥36
36hours
ore a per
week (85%(probabilità
probabilitydiofsuccesso
success),dell’85%),
we suggest
tailoring the
number
settimana
si consiglia
di adeguare
hours todithis
goal. (strong
recommendation).
ilofnumero
ore minimum
a questo obiettivo
minimo.
(raccomandazione forte).
*
Hladunewich MA et al. J Am Soc Nephrol. 2014 May;25(5):1103-9.
Barua M. et al Clin J Am Soc Nephrol. 2008 Mar;3(2):392-6.
Jesudason S. et al.: Clin J Am Soc Nephrol 2014; 9:143
Piccoli GB, Cabiddu G, Castellino S, Gernone G et al. A Best Practice position statement on Pregnancy on Dialysis: The
Italian Study Group on Kidney and Pregnancy. JOURNAL OF NEPHROLOGY. IN PRESS
5. We do not recommend using Kt/V as a measure of dose of
dialysis in pregnancy, due to the lack of studies considering
these markers; pre dialysis urea levels (<100 mg/dL may be
taken as a surrogate) (not graded).
Hladunewich MA et al. J Am Soc Nephrol. 2014 May;25(5):1103-9.
6.
Ameliorating
Do not change
the uremic
the usemilieu
of heparin,
can avoid
which
polyhydramnios,
does not crosshelp
the
control
placenta
hypertension,
and is notincrease
associated
birth
with
weight
morbidity
, gestational
and maternal
age and
maternal
and fetal
nutrition
mortality, but suspend warfarin, which cross the
placenta and are teratogenic.
7. Adapting the prescriptions of bicarbonate, potassium and
calcium to the individual cases, with particular attention to
slow fluid removal, and to progressive increase in weight
during pregnancy (≈ 10 Kg). (not graded)
Cabiddu F, Castellino S, Daidone G, Giannattasio M, Gesualdo L, et al: Linee-guida Rene e Gravidanza.
G. Ital. Nefrol. 2000; 17: 24-46
Piccoli GB, Cabiddu G, Castellino S, Gernone G et al. A Best Practice position statement on Pregnancy on Dialysis: The
Italian Study Group on Kidney and Pregnancy. JOURNAL OF NEPHROLOGY. IN PRESS
Careful
Attentouterine
monitoraggio
and fetal
uterino
monitoring
e fetale
during
durante
hemodialysis
l'emodialisi
and
e prevenire
preventing
l’ipotensione
dialysis induced
intradialitica
hypotension
perchébecause
può essere
may
be
associata
associated
con with
l'induzione
the induction
delle contrazioni
of uterine uterine
contractions
Giatras I et al.: Nephrol Dial Transplant 1998; 13:3266
Dyalisate composition
Hypokalemia - may be a problem with daily
dialysis and pts require dialysate with a 3 to 3.5
mEq/l K+ concentration. In intensively dialyzed PD
pts many of them require K+ supplement.
Hypoposphatemia - may be a feature of an
intensive
dialysis
regimen.
Under
such
circumstances the use of posphate binders is no
longer necessary.
Hou S: Modification of dialysis regimens for pregnancy. Int J artif Organs 2002; 25 (9): 823-6
Nefrologia Putignano
Dyalisate composition
Hypercalcemia - can be avoided with the use of a
bath containing 1.25-1.5 mmol/l calcium. Even a net
influx of calcium (~ 200 mg per treatment) usually
occours (at least 30 g are needed for fetal
development).
Metabolic Acidosis - a lower than usual
bicarbonate bath should be used to avoid metabolic
acidosis and balance the respiratory alkalosis. This
would not be a problem in PD pts where serum
bicarbonate remain in range of 25 mEq/l.
Hou S: Modification of dialysis regimens for pregnancy. Int J artif Organs 2002; 25 (9): 823-6
Nefrologia Putignano
Amount of dialysis required in
Peritoneal Dialysis
There are no guidelines for the amount of dialysis
that should be provided to peritoneal dialysis
patients.
But extrapolating from the experiences with
hemodialysis patients it would be reasonable to try
to double the amount of dialysis delivered.
This require a combination of nighttime and
daytime dialysis.
Hou S: Modification of dialysis regimens for pregnancy. Int J artif Organs 2002; 25 (9): 823-6
Nefrologia Putignano
1.
2.
3.
4.
5.
6.
DIALYSIS SCHEDULE ON PERITONEAL DIALYSIS
The “ideal” type of peritoneal dialysis (CAPD or APD) remains to be
determined (not graded)
Dialysis efficiency has to be increased (not graded).
In CAPD, the prescription should be modified by increasing the
number of exchanges, because large volumes are not well tolerated
especially during the third trimester (a partire dalla 25° settimana,
ridurre il volume del carico fino a 800 ml/scambio) (not graded).
In APD, increase in the total volume and prolonged time, reducing
dwell volumes and increasing the number of cycles (not graded).
In APD, Tidal peritoneal dialysis can be used to avoid drain pain and
reduce gastroesophageal reflux. Tidal regimens may also alleviate
catheter drain dysfunction caused by the enlarging uterus (not
graded).
We do not recommend using Kt/V and or peritoneal creatinine
clearance as a measure of dose of dialysis in pregnancy, due to the
lack of studies considering these markers with respect to pregnancy
outcomes (not graded)
Piccoli GB et al.: JOURNAL OF NEPHROLOGY. IN PRESS
Peritoneal Dialysis Disadvantages
Abdominal fullness, with the possibility of catheter
displacement.
Gastroesophageal reflux.
Drain pain, dialysate flow disturbance.
Hemoperitoneum (occasionally reported in pregnancy.
Severe hemoperitoneum may be a sign of uterine
trauma, uteroplacental detachment, placenta previa,
spontaneous abortion)
The incidence of peritonitis is not reported as increased.
Lew SQ. Perit Dial Int 2006; 26: 108-110.
Chou CY et al . Nephrol Dial Transplant 2006; 21: 1454-1455.
Tuncer M et al. Perit Dial Int 2000; 20: 349-350.
Peritoneal Dialysis Advantages
Continuous treatment with stable metabolic balance.
Gentle daily ultrafiltration (minimizing the acute
fluctuations of intravascular volumes that can
compromise placental blood flow).
Avoiding systemic anticoagulation.
More liberal diet.
Piccoli GB, Cabiddu G, Castellino S, Gernone G et al. A Best Practice position statement on Pregnancy on Dialysis: The
Italian Study Group on Kidney and Pregnancy. JOURNAL OF NEPHROLOGY. IN PRESS
Monitoring weight gain
The weight change between treatments is
due to excess fluid or is a part of the
desired pregnancy-associated weight gain.
In early pregnancy the changes in “dry
weight” should be only 0.9 – 2.3 Kg.
Recommended weight gain in the second
and third trimesters is between 0.3 - 0.5 Kg
per week.
Hou S: Modification of dialysis regimens for pregnancy. Int J artif Organs 2002; 25 (9): 823-6
Nefrologia Putignano
Monitoring weight gain
With daily dialysis the majority of the
change in weight result of fluid gain
The women should have a careful weekly
examination to look signs of pathologic fluid
overload
With
daily
dialysis
volume
related
hypertension should be minimized and if
there is any increase in blood pressure,
particularly during dialysis, the patient
should be evaluated for pre-eclampsia.
Hou S: Modification of dialysis regimens for pregnancy. Int J artif Organs 2002; 25 (9): 823-6
Nefrologia Putignano
Apporto Dietetico
Adottare una dieta adeguata dal punto di vista
proteico e calorico (rispettivamente 1.2 g/Kg e 35
Kcal/Kg in ED e 1.4 g/Kg e 25 Kcal/Kg in DP).
Cabiddu F, Castellino S, Daidone G, Giannattasio M, Gesualdo L, Imbasciati E,
Gregorini G, Manfellotto D, Montanaro D.: Linee-guida Rene e Gravidanza. G.
Ital. Nefrol. 2000; 17: 24-46
Nefrologia Putignano
Anemia
1. Anaemia should be managed with erythropoietin stimulating
agents (ESAs). The Hemoglobin target should be 10-11 g/dL.
Pregnancy is an unusual cause of “erythropoietin
resistance”. A doubling of the erythropoietin dose is usually
required (strong suggestion)
2. The demand of iron is increased. Oral iron is safe, while i.v.
has
showninto
ironErythropoietin
should be managed
withbeen
care specially
thebe
later stages
of pregnancy
up to 80-90% ofinparenteral
iron may
safe andwhen
non-teratogen
pregnancy.
deposited inSienas
theLfetus;
therefore
doses (20-30 mg iron
et al. Obstet
Gynecol Surv. ->
2013 small
Aug;68(8):594-602.
Horowitz KM et al. Clin Lab Med. 2013 Jun;33(2):281-91.
gluconate) maintaining
the transferrin saturation around 30%
and ferritin to 200- 300 mg / ml (strong suggestion)
3. Folate and B12 supplementation should be tailored upon blood
levels. (not graded) Reddy SS et al. Kidney Int. 2009 Jun;75(11):1133-4.
Hou S: Modification of dialysis regimens for pregnancy. Int J artif Organs 2002; 25 (9): 823-6
Piccoli GB, Cabiddu G, Castellino S, Gernone G et al. A Best Practice position statement on Pregnancy
on Dialysis: The Italian Study Group on Kidney and Pregnancy. JOURNAL OF NEPHROLOGY. IN PRESS
Nefrologia Putignano
CALCIUM-PHOSPHATE BALANCE
1. Vitamin D supplementation is safe in pregnancy and may
be required at increased doses (strong suggestion)
2. Calcium containing Phosphate binders are safe (not
graded), while sevelamer may negatively affect foetal
ossification (evidence from animal studies).
3. Attention should also be posed to magnesium levels, since
low levels may favour uterine contraction; oral magnesium
supplementation may be required (strong suggestion).
Podymow T et al. Obstet Gynecol Clin North Am. 2010 Jun;37(2):195-210.
Piccoli GB, Cabiddu G, Castellino S, Gernone G et al. A Best Practice position statement on Pregnancy
on Dialysis: The Italian Study Group on Kidney and Pregnancy. JOURNAL OF NEPHROLOGY. IN PRESS
Maternal Prognosis
The risk of death for a dialysis patient who
becomes pregnant is not increased by the
pregnancy.
Modalità del Parto
Sono legate a esigenze ostetriche
Okundaye I: Registry of Pregnancy in dialysis patients. Am J Kidney Dis 31: 1998; 766-773
Nefrologia Putignano
Conclusioni
La fertilità è un segno di benessere
pertanto, il verificarsi del concepimento in
una paziente dializzata, dovrebbe essere
considerato un segno evidente del successo
che il trattamento dell’ESRD ha avuto.
Nefrologia Putignano
Conclusioni
Pregnancy on dialysis is possible and the reported success
rate is over 70-80% in the last decade.
The risk of death for the mother is very low.
The risk of foetal loss and neonatal death is higher than in
pregnancy after transplantation and is higher in both
cases with respect to the overall population.
Prematurity is the major risk for the baby (1/3 of babies),
it decrease with the increase of dialysis frequency and
time on dialysis with an ideal target of at least 36 hours
per week.
There is no increase of reported malformations.
Nefrologia Putignano
Conclusioni
There is no need a priori to change dialysis modality if the
mother is on PD, but efficiency should be increased as much
as possible, and a shift to haemodialysis may be needed in
the case of suboptimal metabolic control.
A residual renal function is correlated with better pregnancy
outcomes, but pregnancy is possible also in patients with
long term dialysis.
Nefrologia Putignano
“One
day
will reach
point where
Ci sarà
unwe
giorno
in cui iamedici
physicians
regard
childbearing
as a in
guarderanno
alla fertilità
delle donne
goal
treatment
for dialysis
dialisiofcome
un obiettivo
di trattamento
patients
as andaaccident
piuttosto rather
che un than
incidente
trattare to
be
handled
when it
quando
si verifica
" occurs”
Hou S. PDI Vol. 21 (2001), Supplement 3: 290 - 94
Nefrologia Putignano
Grazie per
l’attenzione!
Nefrologia - Putignano