Pregnancy and haemodialyisis: a case study
Embarazo en hemodiálisis, a propósito de un caso
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"paginaInicial" => "261" "paginaFinal" => "268" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "María Ruiz-Campuzano, Silvia Soto-Alarcón, Antonio Martínez-Ruiz, Eladio Lucas-Guillén" "autores" => array:4 [ 0 => array:4 [ "nombre" => "María" "apellidos" => "Ruiz-Campuzano" "email" => array:1 [ 0 => "mariaruc@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "nombre" => "Silvia" "apellidos" => "Soto-Alarcón" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 2 => array:3 [ "nombre" => "Antonio" "apellidos" => "Martínez-Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] 3 => array:3 [ "nombre" => "Eladio" "apellidos" => "Lucas-Guillén" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Rafael Méndez, Lorca, Murcia " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Sección de Nefrología, Hospital Rafael Méndez, Lorca, Murcia, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Embarazo en hemodiálisis, a propósito de un caso" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11061_19157_29378_en_t1_11061.jpg" "Alto" => 878 "Ancho" => 1468 "Tamanyo" => 416385 ] ] "descripcion" => array:1 [ "en" => "Haemodialysis and treatment parameters" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor,</span></p><p class="elsevierStylePara">Pregnancy among patients in periodical haemodialysis programmes is still unusual, conception rates ranging between 0.5% and 1.4%, depending on the series.<span class="elsevierStyleSup">1,2</span> This is due to a number of factors that decrease fertility and the difficult management of pregnancy during dialysis, owing to scarce experience. However, the most recent studies published by different work groups report encouraging pregnancy success rates of nearly 70%, thanks to improved dialysis techniques and better maternal and foetal care.<span class="elsevierStyleSup">3-5</span></p><p class="elsevierStylePara">We present the case of a 35 year old woman with chronic kidney disease secondary to type 1 membranoproliferative glomerulonephritis, diagnosed by renal biopsy in 1989. She started haemodialysis treatment in June 1994 and underwent cadaver-donor kidney transplantation in December 1995.</p><p class="elsevierStylePara">On 11 July 2008, she started periodical haemodialysis treatment again due to chronic allograft nephropathy. Co-morbidities included secondary hyperparathyroidism treated with calcitriol, hyperuricaemia treated with alopurinol, anaemia treated with subcutaneous epoetin alfa and oral iron supplements, and hypertension treated with calcium channel blockers, beta blockers and diuretics.</p><p class="elsevierStylePara">When the patient returned to dialysis, immunosuppressant drugs were gradually discontinued (steroids, calcineurin inhibitors and mycophenolate mofetil) and the patient was transitioned to darbepoetin alfa and intravenous iron supplements Transfusion of 2 units of red blood cells was necessary during the first session due to anaemia with a haemoglobin level of 6.9g.</p><p class="elsevierStylePara">On 13 August 2008 the patient reported amenorrhea lasting 2 months. Human chorionic gonadotropin-beta levels and a vaginal ultrasound revealed that she was approximately 4 weeks pregnant. In light of these results, the patient started a daily haemodialysis programme.</p><p class="elsevierStylePara">For the dialyser, we used a high-flux polyethersulfone membrane with a surface area of 2.1m<span class="elsevierStyleSup">2</span> and a dialysate bath consisting of 3mEq/l calcium and 1.5mEq/l K<span class="elsevierStyleBold"><span class="elsevierStyleSup">+</span></span>, although this was adjusted depending on laboratory results. Dalteparin was administered as an anticoagulant agent at an initial dose of 2500IU per session. Dry weight was adjusted by applying increases of 0.3-0.5kg per week from the second trimester.</p><p class="elsevierStylePara">Regarding drug treatment, tacrolimus was suspended and steroid and calcitriol treatments were maintained. We did not continue to decrease steroids in order to prevent graft rejection, using a dose of 5mg daily. The diuretic agents and the calcium channel blocker were suspended and folic acid and Vitamin B complex were increased. No oral iodine supplement was prescribed due to lack of experience and because it is excreted in urine. The patient received no zinc supplements because plasma levels were normal (Table 1).</p><p class="elsevierStylePara">The patient was placed on an unrestricted diet.</p><p class="elsevierStylePara">Our goal was to maintain pre-dialysis urea levels below 100mg/dl and normal calcium levels, prevent acid-base balance disorders and maintain haemoglobin levels at approximately 11g/dl. The dialysis dose that we established as our target was an equivalent renal urea clearance of 30ml/min according to the Casino and López method.</p><p class="elsevierStylePara">In this case, evolution of anaemia during the pregnancy was slow, and maintaining haemoglobin levels above 9g/dl was difficult. The patient required 2 units of red blood cells in week 21 (Table 2).</p><p class="elsevierStylePara">Session duration was gradually increased from an initial length of 3 hours. After gestation, the patient’s programme consisted of 6 weekly sessions of 4.5 hours (27 hours weekly). No relevant episodes of hypotension were recorded and the maximum ultrafiltration rate was 500ml/h.</p><p class="elsevierStylePara">It was necessary to increase the anticoagulant dose to 5000IU dalteparin per session. The only incident was graft thrombosis in week 24 and doctors placed a jugular tunnelled catheter so as not to expose the patient to thrombolytic drugs or excessive radioscopy.</p><p class="elsevierStylePara">Regarding obstetrics, hypertension was recorded in week 16, and treatment with methyldopa was initiated. Polyhydramnios and foetal macrosomia were detected in week 20. In week 32, the patient was referred to a tertiary hospital for assessment and to end the pregnancy due to the foetal monitor showing poor responsiveness. A planned caesarean section was performed 2 weeks later, delivering a live newborn weighing 2200g.</p><p class="elsevierStylePara">Available information on managing pregnant patients in haemodialysis programmes is scarce; it is mainly based on small cohorts and a handful of meta-analyses published by different hospitals around the world. This highlights the need for creating national and international registers.<span class="elsevierStyleSup">6 </span>In these series, we observed a proportional relationship between the time the patient remained on dialysis and the prognosis for the pregnancy. In general, programmes of more than 20 hours weekly are related to longer gestational periods and decreased risk of preterm birth.<span class="elsevierStyleSup">6</span> It also seems that increasing dialysis frequency to a programme of 6 weekly sessions is better than scheduling longer, less frequent sessions.</p><p class="elsevierStylePara">One hypothesis is that prolonging dialysis sessions may decrease risk of polyhydramnios and foetal distress and improve the patient’s nutritional state, thereby decreasing the risk of preterm birth.<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Anaemia, another chronic complication of patients on dialysis, must be monitored and treated with iron and folic acid supplements, and erythropoietin treatment must be increased in order to maintain haemoglobin levels at 10g/dl and transferrin saturation above 30%.<span class="elsevierStyleSup">8</span></p><p class="elsevierStylePara">Although there is still very little available information on the management of these patients, the most recent published results give us a more optimistic view.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article.</p><p class="elsevierStylePara"><a href="grande/11061_19157_29378_en_t1_11061.jpg" class="elsevierStyleCrossRefs"><img src="11061_19157_29378_en_t1_11061.jpg" alt="Haemodialysis and treatment parameters"></img></a></p><p class="elsevierStylePara">Table 1. Haemodialysis and treatment parameters</p><p class="elsevierStylePara"><a href="grande/11061_19157_29379_en_t2_11061.jpg" class="elsevierStyleCrossRefs"><img src="11061_19157_29379_en_t2_11061.jpg" alt="Laboratory data"></img></a></p><p class="elsevierStylePara">Table 2. Laboratory data</p>" "pdfFichero" => "P1-E534-S3460-A11061-EN.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11061_19157_29378_en_t1_11061.jpg" "Alto" => 878 "Ancho" => 1468 "Tamanyo" => 416385 ] ] "descripcion" => array:1 [ "en" => "Haemodialysis and treatment parameters" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "11061_19157_29379_en_t2_11061.jpg" "Alto" => 572 "Ancho" => 1452 "Tamanyo" => 277090 ] ] "descripcion" => array:1 [ "en" => "Laboratory data" ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003200000002/v0_201502091616/X2013251412000679/v0_201502091617/en/main.assets" "Apartado" => array:4 [ "identificador" => "35437" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor - Brief Case Reports" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/20132514/0000003200000002/v0_201502091616/X2013251412000679/v0_201502091617/en/P1-E534-S3460-A11061-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251412000679?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 8 | 15 |
| 2024 October | 38 | 41 | 79 |
| 2024 September | 37 | 33 | 70 |
| 2024 August | 43 | 47 | 90 |
| 2024 July | 35 | 37 | 72 |
| 2024 June | 54 | 37 | 91 |
| 2024 May | 59 | 29 | 88 |
| 2024 April | 40 | 60 | 100 |
| 2024 March | 31 | 25 | 56 |
| 2024 February | 25 | 26 | 51 |
| 2024 January | 16 | 23 | 39 |
| 2023 December | 25 | 29 | 54 |
| 2023 November | 33 | 34 | 67 |
| 2023 October | 37 | 27 | 64 |
| 2023 September | 34 | 22 | 56 |
| 2023 August | 51 | 11 | 62 |
| 2023 July | 55 | 25 | 80 |
| 2023 June | 52 | 24 | 76 |
| 2023 May | 36 | 35 | 71 |
| 2023 April | 33 | 15 | 48 |
| 2023 March | 34 | 26 | 60 |
| 2023 February | 31 | 19 | 50 |
| 2023 January | 29 | 26 | 55 |
| 2022 December | 39 | 33 | 72 |
| 2022 November | 43 | 23 | 66 |
| 2022 October | 49 | 34 | 83 |
| 2022 September | 37 | 20 | 57 |
| 2022 August | 50 | 51 | 101 |
| 2022 July | 36 | 37 | 73 |
| 2022 June | 37 | 35 | 72 |
| 2022 May | 41 | 34 | 75 |
| 2022 April | 38 | 40 | 78 |
| 2022 March | 36 | 31 | 67 |
| 2022 February | 36 | 38 | 74 |
| 2022 January | 43 | 29 | 72 |
| 2021 December | 46 | 34 | 80 |
| 2021 November | 40 | 42 | 82 |
| 2021 October | 49 | 41 | 90 |
| 2021 September | 36 | 40 | 76 |
| 2021 August | 34 | 37 | 71 |
| 2021 July | 37 | 36 | 73 |
| 2021 June | 36 | 19 | 55 |
| 2021 May | 36 | 33 | 69 |
| 2021 April | 76 | 53 | 129 |
| 2021 March | 72 | 39 | 111 |
| 2021 February | 44 | 23 | 67 |
| 2021 January | 34 | 13 | 47 |
| 2020 December | 25 | 13 | 38 |
| 2020 November | 33 | 12 | 45 |
| 2020 October | 26 | 25 | 51 |
| 2020 September | 18 | 8 | 26 |
| 2020 August | 21 | 10 | 31 |
| 2020 July | 29 | 6 | 35 |
| 2020 June | 29 | 13 | 42 |
| 2020 May | 29 | 12 | 41 |
| 2020 April | 50 | 21 | 71 |
| 2020 March | 19 | 11 | 30 |
| 2020 February | 38 | 29 | 67 |
| 2020 January | 31 | 26 | 57 |
| 2019 December | 37 | 18 | 55 |
| 2019 November | 31 | 20 | 51 |
| 2019 October | 17 | 8 | 25 |
| 2019 September | 25 | 23 | 48 |
| 2019 August | 17 | 9 | 26 |
| 2019 July | 11 | 18 | 29 |
| 2019 June | 18 | 10 | 28 |
| 2019 May | 20 | 24 | 44 |
| 2019 April | 54 | 28 | 82 |
| 2019 March | 20 | 20 | 40 |
| 2019 February | 20 | 15 | 35 |
| 2019 January | 19 | 22 | 41 |
| 2018 December | 72 | 39 | 111 |
| 2018 November | 97 | 21 | 118 |
| 2018 October | 94 | 14 | 108 |
| 2018 September | 67 | 20 | 87 |
| 2018 August | 44 | 17 | 61 |
| 2018 July | 64 | 18 | 82 |
| 2018 June | 61 | 12 | 73 |
| 2018 May | 65 | 22 | 87 |
| 2018 April | 65 | 10 | 75 |
| 2018 March | 69 | 15 | 84 |
| 2018 February | 74 | 11 | 85 |
| 2018 January | 61 | 8 | 69 |
| 2017 December | 72 | 12 | 84 |
| 2017 November | 58 | 13 | 71 |
| 2017 October | 39 | 11 | 50 |
| 2017 September | 46 | 12 | 58 |
| 2017 August | 39 | 7 | 46 |
| 2017 July | 54 | 13 | 67 |
| 2017 June | 53 | 7 | 60 |
| 2017 May | 37 | 11 | 48 |
| 2017 April | 42 | 13 | 55 |
| 2017 March | 37 | 13 | 50 |
| 2017 February | 27 | 16 | 43 |
| 2017 January | 26 | 16 | 42 |
| 2016 December | 42 | 7 | 49 |
| 2016 November | 53 | 13 | 66 |
| 2016 October | 77 | 14 | 91 |
| 2016 September | 106 | 4 | 110 |
| 2016 August | 163 | 5 | 168 |
| 2016 July | 157 | 10 | 167 |
| 2016 June | 128 | 0 | 128 |
| 2016 May | 138 | 0 | 138 |
| 2016 April | 124 | 0 | 124 |
| 2016 March | 86 | 0 | 86 |
| 2016 February | 108 | 0 | 108 |
| 2016 January | 103 | 0 | 103 |
| 2015 December | 132 | 0 | 132 |
| 2015 November | 107 | 0 | 107 |
| 2015 October | 86 | 0 | 86 |
| 2015 September | 65 | 0 | 65 |
| 2015 August | 68 | 0 | 68 |
| 2015 July | 68 | 0 | 68 |
| 2015 June | 43 | 0 | 43 |
| 2015 May | 41 | 0 | 41 |
| 2015 April | 13 | 0 | 13 |
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