Dr Katherine Richards1, Dr Sumanthi Rajendran1, Dr Alice Burton1, Dr Rajit Narayan1, Dr Erin Vaughan1
1Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
Biography:
Biographies to come
Abstract:
Introduction: The management of advanced chronic kidney disease (CKD) in pregnancy poses diagnostic and therapeutic challenges and requires sub-specialized multi-disciplinary care. This case series of three pregnancies, details the specific initiation and titration of haemodialysis therapy.
Case Series: This single-centre retrospective case series from 2018-2024 involves three pregnant patients with CKD due to IgA and diabetic nephropathy. Aspirin 150mg prophylaxis was commenced before 14 weeks gestation. Dialysis was initiated between 9 to 24 weeks gestation due to combinations of elevated serum urea, polyhydramnios and severe hypertension. SFlt-1 to PlGF ratios were monitored in two pregnancies as a clinical adjunct to identify superimposed preeclampsia, but did not contribute significantly to management decisions. Tailored dialysis protocols aimed to maintain pre-dialysis serum urea levels below 12.5mmol/L. Additional management included erythropoietin, iron and adjusted perinatal vitamin supplementation as well as multiple antihypertensive agents. Multi-disciplinary review by sub-specialised Obstetricians, nursing, midwifery and allied health professionals were essential for individually designed maternal and foetal care. Despite intensive management, all pregnancies resulted in preterm deliveries by emergency caesarian section at gestational ranges of 25+4 to 32+1 weeks. Two patients remained dialysis-dependent, one subsequently received a kidney transplant and one transplant wait-listed. Dialysis is being weaned for the final patient, who is currently one-month postpartum.
Conclusion: This series contributes further understanding to the complex management of pregnant CKD patients requiring dialysis initiation and highlights the importance of multi-disciplinary management. Preconception counselling and close monitoring are crucial for optimising maternal and foetal outcomes. Though monitored, sFlt-1 to PlGF ratios had limited impact on clinical decisions, indicating while biomarkers provide placental function insights in non-CKD pregnancies, their utility in advanced CKD continues to be explored. These findings highlight the need for development of standardised dialysis initiation protocols and further research to optimise diagnostic and management strategies in this high-risk population.
Keywords
dialysis, kidney, pregnancy