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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#58;</span></p><p class="elsevierStylePara">Although it is uncommon for females with chronic renal failure to become pregnant while on haemodialysis&#44; there is a clear increase in the number of such cases published in the medical literature with a notable success rate&#44; possibly due to the improvements made in dialysis techniques and obstetric care&#46; However&#44; we must not underestimate the risks and complications associated with pregnancy in patients on renal replacement therapy&#46;<span class="elsevierStyleSup">1-3</span></p><p class="elsevierStylePara">Here we report on our experience with a 32-year old female patient with chronic renal failure on a periodical haemodialysis programme and who intended to be pregnant&#46; The patient&#8217;s clinical history included&#58; chronic kidney disease secondary to a glomerulopathy that had not been biopsied&#44; arterial hypertension&#44; dyslipidaemia&#44; chronic lymphocytic thyroiditis&#47;sub-centimetre nodular goitre&#44; perennial allergic rhinoconjunctivitis&#44; and secondary renal hyperparathyroidism on treatment with cinacalcet&#46;</p><p class="elsevierStylePara">We immediately modified the patient&#8217;s treatment regimen&#44; suspending losartan and atorvastatin and maintaining anti-hypertensive treatment with doxazosin and atenolol&#46; Seven weeks after deciding to become pregnant&#44; the patient developed amenorrhoea&#44; and gestation was confirmed with a positive beta-chorionic gonadotropin blood test&#46; We then proceeded to modify the patient&#8217;s dialysis regimen&#44; switching to 6 sessions per week of 4 hours each &#40;24h&#47;week&#41; and haemodiafiltration with endogenous re-infusion&#46; The calcium concentration in dialysate was lowered in order to avoid a positive calcium balance&#44; and the potassium concentration was increased in order to avoid hypopotassaemia&#46; We also modified the concentration of bicarbonate in the dialysate solution&#44; initially lowering it to 25mEq&#47;l in order to avoid metabolic acidosis&#44; but then increasing it to 30mEq&#47;l due to post-haemodialysis metabolic acidosis&#46; For intra-dialytic anti-coagulation therapy&#44; we administered 20mg enoxaparin &#40;intravenous&#41; during each session&#46; Ultrafiltration was limited to 500ml&#47;h in order to avoid sharp decreases in blood pressure&#44; which heavily influences placental perfusion&#46; As regards medical treatment&#44; atenolol and doxazosin were replaced by methyldopa&#44; and omeprazole was replaced by almagate&#59; we reduced the dosage of cinacalcet&#44; which was completely suspended after 7 weeks of gestation due to the lack of information regarding its use in pregnant women&#46; We used calcium acetate as a phosphate binder&#46; As regards other medications&#44; the patient received oral iodine&#44; vitamin C and B complex&#44; folic acid&#44; and carnitine 3 times per week&#46; We did not limit the patient&#8217;s dietary intake except for salt restrictions&#46;<span class="elsevierStyleSup">4&#44;5</span></p><p class="elsevierStylePara">During the first 22 weeks of gestation&#44; the patient received dialysis in a peripheral dialysis centre in collaboration with her reference hospital&#44; and went through regular controls in a high-risk pregnancy consultation&#46; Weekly measurements were taken for haemoglobin&#44; leukocytes and pre-haemodialysis platelets and urea&#44; creatinine&#44; total protein&#44; urea nitrogen&#44; sodium&#44; potassium&#44; phosphorous and pre&#47;post-haemodialysis calcium&#46; We also measured pre&#47;post-haemodialysis acid-base balance every other week&#46;</p><p class="elsevierStylePara">During this period&#44; it was very difficult to control the patient&#8217;s blood pressure&#44; requiring a progressive increase in hypotensive medications&#44; which reached a dosage of 2g&#47;d of methyldopa and 1g&#47;d of labetalol&#46; In week 16 of gestation&#44; we also added diazepam&#46;</p><p class="elsevierStylePara">In week 20 of pregnancy&#44; the patient was diagnosed with total occlusive placenta pregnancy&#46;</p><p class="elsevierStylePara">In week 22 of gestation&#44; the patient was admitted to the hospital with a hypertensive crisis and heart failure&#46; From this moment onwards&#44; the patient was treated with 7 sessions of dialysis per week of 4 hours each&#44; and in week 28&#44; the regimen was increased to 6 hours per session&#44; thus reducing the intensity of haemodialysis &#40;blood flow and dialysate flow were programmed to 175ml&#47;minute and 200ml&#47;minute&#44; respectively&#41; in order to achieve better control of body volume and blood pressure&#46; For intra-dialytic anti-coagulation therapy&#44; we switched the patient from enoxaparin to sodium heparin at an initial dose of 15mg and 5mg&#47;hour thereafter&#46; The patient was maintained on a daily haemodialysis regimen until the end of pregnancy&#46; During this period&#44; blood pressure continued to fluctuate&#44; requiring high doses of hypotensive drugs&#58; hydralazine at 100mg&#47;day&#44; methyldopa at 2g&#47;day&#44; and labetalol at 1200mg&#47;day&#46; Given the difficulties in maintaining appropriate blood pressure&#44; the patient was hospitalised until the end of pregnancy&#46;</p><p class="elsevierStylePara">As regards the treatment of anaemia&#44; the patient&#8217;s requirements for erythropoietin &#40;EPO&#41; increased progressively&#46; At the beginning of gestation&#44; we administered a weekly dose of 18&#160;000IU&#44; and by week 22 the dosage had been increased to 30&#160;000IU&#47;week&#44; maintaining haemoglobin values at 10&#46;5-11&#46;5g&#47;dl&#46; During hospitalisation&#44; the dose of EPO was elevated to 42&#160;000IU&#47;week&#44; maintaining haemoglobin values around 10g&#47;dl&#46; The patient also required iron sucrose at 100mg&#47;week throughout the pregnancy&#46; We also administered monosodium phosphate &#40;30mEq&#41; and magnesium sulphate &#40;12mEq&#41; during dialysis&#44;<span class="elsevierStyleSup">5&#44;6</span> which was given during the fourth hour of each session&#59; we also gave the patient a banana during the second hour of dialysis as a potassium supplement&#46;</p><p class="elsevierStylePara">Blood urea nitrogen levels were maintained below 40mg&#47;dl during the entire pregnancy&#46;</p><p class="elsevierStylePara">The evolution of laboratory parameters is summarised in the Table 1&#46;</p><p class="elsevierStylePara">In week 23 of pregnancy&#44; the patient gave birth through caesarean due to delayed intra-uterine growth and arterial hypertension&#44; giving birth to a healthy pre-term male of 1&#46;3kg&#46;</p><p class="elsevierStylePara">The patient gained 230g&#47;week of weight until hospitalisation&#59; afterwards&#44; and despite appropriate intra-uterine growth of the foetus until a few days prior to the caesarean birth&#44; the patient&#8217;s weight stabilised and even started to decrease&#44; with a similar weight at week 32 to that recorded at the start of pregnancy&#46; Residual diuresis remained at 800ml&#47;day throughout most of the pregnancy&#46;</p><p class="elsevierStylePara">In puerperium&#44; the patient developed another episode of heart failure and hypertensive crisis in the context of hydrosaline overload&#44; which was resolved by decreasing dry weight &#40;upon discharge it was 10kg less than at the start of the pregnancy&#41;&#46; Coinciding with these findings&#44; we also detected decreased values for haemoglobin&#44; thrombocytopenia&#44; elevated lactate dehydrogenase &#40;LDH&#41;&#44; and increased transaminase levels in laboratory test results&#46; A peripheral blood smear was normal&#44; ruling out haemolysis&#46; A direct Coombs test was also negative&#46;</p><p class="elsevierStylePara">Following birth&#44; we observed a complete recovery in clinical and laboratory parameters for the mother&#44; but she still required 6 hypotensive drugs in order to control blood pressure&#46;</p><p class="elsevierStylePara">Monitoring pregnancy in patients on dialysis requires strict multi-disciplinary control&#44; and we believe that individual experiences and those reported in reviews of case reports are very important for reaching a consensus or shared criterion for managing and treating these patients&#44; so as to achieve a greater rate of success and maternal&#47;foetal survival&#46;<span class="elsevierStyleSup">7&#44;8</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span></p><p class="elsevierStylePara">The authors state that they have no potential conflicts of interest related to the content of this article&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><a href="grande&#47;11614&#95;108&#95;39901&#95;en&#95;t116&#46;jpg" class="elsevierStyleCrossRefs"><img src="11614_108_39901_en_t116.jpg" alt="Evolution of laboratory parameters during pregnancy"></img></a></p><p class="elsevierStylePara">Table 1&#46; Evolution of laboratory parameters during pregnancy</p>"
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