In-depth ReviewPregnancy in chronic renal insufficiency and end-stage renal disease
Section snippets
Chronic renal insufficiency
The most compelling problem that distinguishes women with renal insufficiency from other women with renal disease who conceive is the loss of renal function. Although hypertension and increased proteinuria are common in all women with renal disease who conceive, there appears to be a critical degree of renal insufficiency that puts a woman who becomes pregnant at risk for an accelerated decline in renal function. This observation is long standing, but systematic evidence to support it has been
Pregnancy in dialysis patients
Fertility is markedly reduced in dialysis patients. Estimates of the frequency of conception in dialysis patients ranges from 1.4% per year in Saudi Arabia16 to 0.5% in the United States.15 Both these estimates are based on surveys that covered only half the women of childbearing age treated with dialysis. A report from Belgium, based on a survey to which all the dialysis units in the country responded, put the frequency at 0.3% per year.17 There is a widespread impression that conception in
Pregnancy in transplant recipients
Fertility is usually restored in women with renal transplants, and pregnancy is common, occurring in 12% of the women of childbearing age in one series.24 The recovery of fertility is less common in women who undergo transplantation close to the end of their childbearing years.
Preconception counseling
Women of childbearing age being considered for renal transplantation who are not rubella immune should receive the rubella vaccine before transplantation because live virus vaccines are contraindicated posttransplantation (Table 2).
Pretransplantation Rubella vaccine Criteria for advising pregnancy 2 years posttransplantation Stable renal function with creatinine ≤2.0 mg/dL BP ≤140/90 mm Hg on medications Proteinuria <500 mg
Infections
Both dialysis patients and transplant recipients face the risk for infection during pregnancy. Women transplant recipients are at increased risk for bacterial infections during pregnancy. Forty percent have urinary tract infections, and these women should have monthly screening urine cultures.35 If asymptomatic bacteriuria is present, the patient should be treated for 2 weeks and may be treated with suppressive doses of antibiotics for the rest of the pregnancy. At the time of delivery,
Worsening renal function in the pregnant transplant recipient
The differential diagnosis and initial workup of worsening renal function in the pregnant transplant recipient are listed in Table 3.
Differential Diagnosis Initial Workup Preeclampsia Blood pressure Cyclosporine toxicity Cyclosporine level Acute rejection Renal ultrasound Chronic rejection Urine culture Recurrent disease 24-Hour urine protein Hemolytic uremic syndrome LDH, transaminases, uric acid Pyelonephritis CBC Obstruction Platelet count,
Anemia
The hematocrit decreases almost invariably in hemodialysis patients who conceive. Transplant recipients and women with renal insufficiency may also have a decrease in hematocrit greater than that seen in normal pregnancy. The reason for anemia is not clear, but it appears to be more complicated than simple iron deficiency.
Choice of modality
When the first cases of pregnancy in peritoneal dialysis patients were reported, it appeared that the outcome was better for peritoneal dialysis patients than for hemodialysis patients.78 With the accumulation of more data, it has become clear that the apparent superiority of peritoneal dialysis simply reflected the overall improvement in outcome for pregnancies in dialysis patients compared with earlier reports.15
There are theoretical advantages to peritoneal dialysis in that there are no
Calcium and phosphorus
Thirty grams of calcium are necessary for calcification of the fetal skeleton. If the patient is dialyzed on a bath containing more than 3.5 mEq/L of calcium, dialysis easily provides this amount. If she is dialyzed on a lower calcium bath, enough calcium should be absorbed from phosphate binders if she takes at least 2 g of calcium daily. 1,25 Dihydroxyvitamin D preparations, either oral or intravenous, are usually continued, although their effect in pregnancy is not well understood. The
Nutritional considerations
Providing a dietary prescription for the pregnant dialysis patient requires extrapolation from the usual diet prescribed for healthy pregnant women and that prescribed for a nonpregnant dialysis patient.82 Tentative guidelines are listed in Table 4.
Calories HD 35 kcal/kg/d + 300 kcal PD 25 kcal/kg + 300 kcal Protein HD 1.2 g/kg ideal pregravid weight + 10 g PD 1.4 g/kg ideal pregravid weight + 10 g + dialysate losses Vitamins A No
Obstetric management
Care of the pregnant dialysis patient and transplant recipient requires close cooperation between the nephrologist and a high-risk pregnancy specialist experienced in treating women with renal disease. A neonatologist should be prepared for the care of a newborn of a mother with renal disease.
Management issues in the newborn
Infants born to both dialysis patients and transplant recipients should be observed in a high-risk setting even if they appear healthy. Infants of dialysis patients are born with blood urea nitrogen and creatinine levels equal to the mother's, and they generally experience an osmotic diuresis after birth. Without careful monitoring and replacement, they develop volume contraction and electrolyte abnormalities.84
Calcium should be monitored carefully because infants exposed to hypercalcemia are
Conclusion
Pregnancy in the transplant recipient can be anticipated and planned for. Under the appropriate circumstances, physicians may encourage it and the desire for parenthood may even influence the decision to undergo transplantation. Although one might have anticipated severe problems for the fetus exposed to immunosuppressive drugs, the problems encountered to date are manageable and do not compare with the risk to the fetus of renal failure.
For women with chronic renal insufficiency and for
References (84)
- et al.
Successful pregnancy in primary glomerular disease
Kidney Int
(1986) - et al.
Pregnancy in women with renal disease and moderate renal insufficiency
Am J Med
(1985) - et al.
Pregnancy in women with chronic renal failure
Am J Obstet Gynecol
(1990) - et al.
Diabetic nephropathy: Pregnancy performance and fetomaternal outcome
Am J Obstet Gynecol
(1988) - et al.
Does pregnancy increase the risk for development and progression of diabetic nephropathy
Am J Obstet Gynecol
(1996) - et al.
Diabetic nephropathy and perinatal outcome
Am J Obstet Gynecol
(1981) Glomerular filtration and volume regulation in gravid animal models
Baillières Clin Obstet Gynecol
(1994)- et al.
A registry for pregnancy in dialysis patients
Am J Kidney Dis
(1998) - et al.
Pregnancy in chronic hemodialysis patients in the Kingdom of Saudi Arabia
Am J Kidney Dis
(1992) - et al.
Pregnancy and dialysis
Am J Kidney Dis
(1998)
Gynecologic and reproductive issues in women on dialysis
Am J Kidney Dis
Hyperprolactinemia in patients with renal insufficiency and chronic renal failure requiring hemodialysis or continuous ambulatory peritoneal dialysis
Am J Kidney Dis
Effect of pregnancy on long-term function of renal allografts
Am J Kidney Dis
The effect of pregnancy on kidney function in renal allograft recipients
Kidney Int
The transplacental passage of prednisone and prednisolone in pregnancy near term
J Pediatr
Parenthood following renal transplantation
Kidney Int
Immunosuppression during pregnancy. Transmission of azathioprine and its metabolites from mother to fetus
Am J Obstet Gynecol
Pregnancy in renal allograft recipients: Prognosis and management
Clin Obstet Gynaecol (Bailliére's)
Pregnancy in liver transplant recipients: Course and outcome in 19 cases
Am J Obstet Gynecol
Effects of diuretics on plasma volume in pregnancies with long-term hypertension
Am J Obstet Gynecol
Propranolol administration during pregnancy: Effects on the fetus
Pediatrics
Long-term propranolol therapy in pregnancy: Maternal and fetal outcome
Am J Obstet Gynecol
Maternal and fetal cardiovascular indices during fetal hypoxia due to cord compression in chronically cannulated sheep
Am J Obstet Gynecol
Final report of study on hypertension during pregnancy: The effects of specific treatment on growth and development of the children
Lancet
Magnesium plus nifedipine: Potentiation of hypotensive effect in preeclampsia?
Am J Obstet Gynecol
Malignant ventricular arrhythmias in eclampsia: A comparison of labetolol with dihydralazine
Am J Obstet Gynecol
Pregnancy in patients on chronic ambulatory peritoneal dialysis
Am J Kidney Dis
Congenital cytomegalovirus infection after maternal renal transplantation
Lancet
Medical management of the pregnant transplant recipient
Adv Ren Replacement Ther
Congenital cytomegalovirus infection: A long-standing problem still seeking a solution
Am J Obstet Gynecol
Intrauterine herpes simplex virus infections
J Pediatr
Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome)
Am J Obstet Gynecol
Pregnancy in women with end-stage renal disease: Treatment of anemia and premature labor
Am J Kidney Dis
Management of the pregnant dialysis patient
Adv Ren Replacement Ther
Medical nutrition therapy in pregnancy and kidney disease
Adv Ren Replacement Ther
Obstetric care for renal allograft recipients or for women treated with hemodialysis or peritoneal dialysis during pregnancy
Adv Ren Replacement Ther
Neonatal outcome in pregnancies associated with renal replacement therapy
Adv Ren Replacement Ther
Pregnancy in women with chronic renal failure
Am J Nephrol
Pregnancy in glomerulonephritic patients with decreased renal function
Hypertens Pregnancy
Pregnancy in women with impaired renal function
Clin Nephrol
Outcome of pregnancy in women with moderate or severe renal insufficiency
N Engl J Med
Pregnancies in women with diabetic nephropathy: Long-term outcome for mother and child
Diabetologia
Cited by (274)
Pregnancy and sex hormone changes after kidney transplant
2023, Clinica e Investigacion en Ginecologia y ObstetriciaFalse Positive Pregnancy Test Before Kidney Transplant: Case Report and Review of Literature
2022, Transplantation ProceedingsPregnancy in Kidney Transplant Recipients
2020, Advances in Chronic Kidney DiseaseChronic Kidney Disease and Pregnancy
2020, Advances in Chronic Kidney DiseaseFertility and pregnancy in systemic lupus erythematosus
2020, Systemic Lupus Erythematosus: Basic, Applied and Clinical Aspects
Received January 30, 1998; accepted in revised form July 24, 1998.
Address reprint requests to Susan Hou, MD, Section of Nephrology, Rush Presbyterian St Luke's Medical Center, 1653 West Congress Pkwy, Chicago, IL 60612. E-mail: [email protected]