Hemodialysis International 2016; 20:339–348

Home Hemodialysis
Intensive dialysis and pregnancy

Michelle HLADUNEWICH1 Dori SCHATELL2

1
Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, University of
Toronto, Toronto, Ontario, Canada; 2Executive Director, Medical Education Institute, Inc., Madison,
Wisconsin, USA

Abstract
Pregnancy in women with end stage renal disease on renal replacement therapy is uncommon due
to the physiologic changes associated with renal failure as well as the complexities and risk involved
in managing these patients. As most of these women had long periods of illness with chronic kidney
disease, the effects of their chronic illness together with the current societal trends to delay child
bearing to a more advanced maternal age can hamper fertility. For those able to conceive, intensified
hemodialysis (HD), through longer and/or more frequent dialysis sessions, offers improved maternal
and neonatal outcomes. Intensified HD is most conveniently offered in the patient’s home, where
possible. This review expands the scope of the Implementing Hemodialysis in the Home website and
associated supplement published previously in Hemodialysis International and includes information
tailored to women of reproductive age. We describe the necessary counseling that women should
receive before conception and before intensification of HD, and provide a detailed management strat-
egy that includes nephrologic and obstetric care, should pregnancy occur.

Key words: End-stage renal disease, home hemodialysis, intensified dialysis, obstetric,
pregnancy

Correspondence to: M. Hladunewich, MD, BSc, MSc,
FRCPC, Sunnybrook Health Sciences Centre, A139 2075
Bayview Avenue, Toronto, ON M4N 3M5, Canada. E-mail:
michelle.hladunewich@sunnybrook.ca
Conflict of Interest: None.
Disclosure of grants or other funding: MH and DS have no dis-
closures to report. Baxter Healthcare provided financial sup-
port for the creation and distribution of these resources
through support to the healthcare communications agency,
The JB Ashtin Group, Inc., including amounts for each mem-
ber of The Global Forum to attend 1 meeting, and a to-be-
determined amount for publication costs. The meeting was
held on 20 May 2015 in Chicago, Illinois, USA. There was no
involvement of Baxter Healthcare or other external sponsors
in the development of Global Forum resources. No direct
financial support was provided to authors, other than for
expenses relating to travel and accommodation for the afore-
mentioned meeting.
INTRODUCTION
Historically, pregnancy among women with end-stage
renal disease (ESRD) who were on dialysis was extremely
unlikely. When pregnancy did occur, it was typically
accompanied by significant risk to both mother and child
due to the many complexities associated with managing
this population of high-risk patients. As such, clinicians
often advised women of reproductive age on dialysis
against becoming pregnant, and those patients who did
not receive a timely transplant were unlikely to have a
child. However, in the last few decades great progress has
been made in the care of hemodialysis (HD) patients.
With the advent of erythropoiesis stimulating agents,
more biocompatible membranes, and intensification of
the delivered dose of HD, pregnancy in women on HD
has become feasible and safer. A recent meta-regression
analysis noted a large increase in number of reported
cases of pregnancy in women on HD (n 5 616 pregnan-
cies from 2000 to 2014)1 compared with a similar

C 2016 The Authors. Hemodialysis International published by Wiley Periodicals, Inc. on behalf of International Society for
V
Hemodialysis.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
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and no modifications or adaptations are made.
DOI:10.1111/hdi.12420 339
Hladunewich and Schatell
systematic review completed less than a decade earlier
(n 5 90 from 2000 to 2008).2 The 2015 publication
reviewed a large collection of case series and case reports,
and reported that the number of hours of HD provided
weekly was significantly inversely correlated with preterm
delivery (<37 wk gestation) and delivery of small for ges-
tational age babies (SGA; less than the 10th percentile),
while the number of sessions of hemodialysis per week
was also associated SGA babies.1 As such, it is becoming
standard of care to significantly increase dialysis intensity
during pregnancy.
Although increased dialysis intensity is, in many cases,
delivered to a pregnant patient through daily visits to an
outpatient HD unit, the expanded use of home HD allows
for the greater flexibility that most young women need to
be able to adequately increase intensity so that fertility
can be enhanced, making pregnancy both possible and
successful.
This review expands the scope of the Implementing
Hemodialysis in the Home website (www.home-hemodialy-
sis.com) and associated supplement published previously
in Hemodialysis International and includes information tai-
lored to women of reproductive age. We will describe the
necessary counseling that every young woman of repro-
ductive age who is initiated on intensified home HD
should receive, and provide a detailed management strat-
egy that includes nephrologic and obstetric care, should
pregnancy occur.
FERTILITY IN WOMEN WITH ESRD
Although the precise mechanisms that contribute to infer-
tility in women with ESRD are not fully understood, con-
siderable hormonal changes and issues with sexual
function occur as a young woman’s kidneys fail. Most
women with ESRD experience amenorrhea due to
decreased levels of estrogen and progesterone, which can
result in significant changes to uterine morphology,
including atrophy.3 Even in women who continue to
menstruate, anovulatory cycles are typical due to aberrant
follicle-stimulating hormone levels and the absence of the
cyclical surge of luteinizing hormone necessary for ovula-
tion.4 Sexual dysfunction resulting from general lack of
interest in sexual activity is also common among women
with ESRD and may be caused by medication side effects,
fatigue, symptoms of depression, and altered body image
(owing to the presence of catheters or fistulas).5–7 As
such, pregnancy incidence in women on HD has been
documented to be very low.8–11 The most comprehensive
study conducted included all HD units in Belgium and
reported a pregnancy rate beyond the first trimester of
340
only 0.3 per 100 patient years (15 cases in 1472 females
of childbearing age over 4545 patient years).8 Docu-
mented pregnancy rates for patients on peritoneal dialysis
(PD), for unclear reasons, are even lower, occurring at
approximately half the rate of that reported for HD
patients.12,13
Innovations in HD, though, are reflected in increased
pregnancy rates over time, and have been described in
data from the United States,13 Canada,14 and the Australia
and New Zealand Dialysis and Transplant (ANZDATA)
registry.12 Further, data from Toronto, where patients
achieve significantly higher clearance rates with intensive
nocturnal HD, conception rates are higher than previously
reported cohorts, with 15.6% of eligible women conceiv-
ing between 2001 and 2006 (7 cases in 45 females of
childbearing age over 225 patient-years or 3 per 100
patient-years).14,15 This is likely due to normalization of
the hypothalamic–pituitary–gonadal axis, as evidenced by
the return of regular menstrual cycles in more intensively
dialyzed young women.16 As such, counseling about the
possibility of pregnancy should occur in all women of
reproductive age, particularly when the therapeutic plan
is to intensify the delivered dialysis dose. If a woman
does not want to have children, contraception is neces-
sary. There is a paucity of data to guide the most appro-
priate contraception options in women with ESRD who
are on HD, so referral to a gynecologist for assessment
and individualized recommendations is appropriate to
review the benefits and potential side effects of different
contraception methods.
PREGNANCY RISKS AND OUTCOMES
IN WOMEN WITH ESRD
Women who receive a kidney transplant have increased
potential for conception because fertility is restored. In
addition, the sexual dysfunction from physical and/or
psychological causes typically improves.17–20 Further,
women who have received kidney transplants typically
have better pregnancy outcomes compared with women
on dialysis. Improvements include a significantly lower
risk of placental abruption, intrauterine growth restric-
tion, and fetal death, but comparisons were made with
more conventional HD regimens.21,22 As such, transplan-
tation options should be reviewed with women while
they are on dialysis, before attempting conception. How-
ever, in the absence of a living related donor, long wait
times may prevent transplant as a viable option in a
woman approaching the limits of her reproductive
window.
Hemodialysis International 2016; 20:339–348
 HD and pregnancy

Table 1 Documented pregnancy outcomes in series reporting over 10 pregnancies on hemodialysis

Country of Origin Japan23 Brazil24 Saudi Arabia25 Italy21 Canada15
Period, y 1986–2007 1988–2008 1992–2003 2000–2012 2000–2013
Total pregnancies, n 28 52 12 20 22
Conception before RRT initiated, n 4 28 5 4 4
Hours of HD per week 18 6 4 15 (9–21) 4–6 sessions/wk 24 6 5 43 6 6
Live birth rate 64% 87% 58% NR 86%
Gestational age, wk 6 SD or (range) 28.3 6 9 32.7 6 3.1 31.5 (27–36) 31.6 6 3.6 36 (32–37)
Birth weight, g 6 SD or (range) 1414 6 759 1554 6 663 1700 (1115–2300) 1401 6 512 2118 6 857
Preterm delivery (<37 wk) 92% 85% 100% 89% 53%
Transfusions 32% 25% 0 NR 0%
Hypertension 39% 70% NR 53% 18%
Preeclampsia/HELLP NR 19% 67% 21%/5% 5%
Polyhydramnios 39% 40% 42% NR 5%
Low birth weight (<2500 g) 94% NR 100% 100% 44%
Very low birth weight (<1500 g) 33% NR 29% 70% 6%
Incompetent cervix 14% NR NR NR 18%
Caesarean delivery 38% 65% 57% 95% 9%
HD 5 hemodialysis; HELLP 5 hemolysis, elevated liver enzymes, low platelet count; NR 5 not reported; RRT 5 renal replacement
therapy; SD 5 standard deviation.

When transplantation is not imminent or is not an
option, the use of intensive HD may be considered to
maximize fertility and improve pregnancy outcomes.
Women who desire a child require counseling to discuss
the optimal timing for a pregnancy and the potential risks
to the mother and baby should pregnancy proceed while
the patient is on HD (Table 1). Specific maternal risks
include loss of residual renal function, exacerbation of
hypertension and preeclampsia, and the need for transfu-
sions. Additionally, there is the potential for immunologi-
cal sensitization from transfusions and the pregnancy
itself that could complicate future transplantation pros-
pects. Risks to the fetus include growth restriction and a
myriad of potential complications associated with prema-
ture birth.
PREPREGNANCY CONSIDERATIONS
In addition to providing detailed counseling to patients
on the potential for pregnancy-associated risks, women
with ESRD require extra care to optimize their health
before conception (Table 2). This includes performing
a full medication review and discontinuing drugs that
have the potential to harm the fetus. Patients with
ESRD are frequently prescribed angiotensin receptor
blockers or angiotensin converting enzyme inhibitors
and statins, all of which ideally should be discontinued
before conception. Although recent studies have failed
to associate first trimester exposure with significant ter-
atogenicity,28,29 pregnancy diagnosis can be delayed in
this patient population due to the menstrual irregular-
ities often associated with ESRD. As such, optimizing
blood pressure control with pregnancy-safe antihyper-
tensive agents preconception is preferred. Management
of other comorbidities, including diabetes or lupus,
should also be optimized before conception. The Amer-
ican Diabetes Association recommends maintenance of
hemoglobin A1C levels <7.0% before conception.30
Women with lupus may have positive anti-Ro and anti-
La antibodies and should be informed about the risk of
congenital heart block (approximately 2%), and neona-
tal cutaneous lupus (approximately 5%).31 Fetal echo-
cardiography between 18 and 24 wk is recommended
in patients with positive antibodies. Clinicians should
ensure that the patient’s medications include a folic
acid supplement and ample water-soluble vitamins.
Intensification of the dialysis dose is typically required to
enhance fertility, bearing in mind that women with ESRD
may reach menopause earlier than women with normal
kidney function (median age of 47.7 y compared to 51 in
the general population).32 Further, the effects of their
chronic illness and possible past exposure to medications
like cyclophosphamide may hamper reproductive poten-
tial. As such, a careful assessment of a woman’s menstrual
history, with input from a reproductive medicine specialist,
may be necessary to determine if conception is feasible.
Unfortunately, there are no data as yet on the safety or
effectiveness of assisted reproductive technologies in this

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Hladunewich and Schatell

Table 2 Management strategy for women with ESRD on intensive dialysis26,27

Prepregnancy Counseling and Health Optimization
 Perform a thorough medication review for potentially teratogenic medications
䊊 Stop renin-angiotensin system blockade, statins, etc.
 Convert to pregnancy-safe antihypertensive agents as required
䊊 Options include methyldopa, labetalol, or long-acting nifedipine
䊊 Target BP < 140/90 mmHg
 Initiate folic acid 5 mg daily
 Ensure the patient is taking usually prescribed renal multivitamins
 Optimize management of comorbid conditions where appropriate (e.g., diabetes, lupus)

Renal Care
Hemodialysis Prescription
 If no residual renal function, minimum required HD is typically 36 h/wk
䊊 Women with residual kidney function may not require as much HD
 Target a near normal urea of approximately 10–15 mmol/L predialysis following the day break
 Determine ultrafiltration goals through frequent physical assessments (at least weekly) to target post-dialysis BP < 140/
90 mmHg and to avoid intradialytic hypotension (<120/70 mmHg)
 Use unfractionated heparin for anticoagulation per usual center-specific protocols, which is safe during pregnancy.

Electrolytes and Calcium-Phosphate Balance

 Monitor closely (weekly or every other week)
 Typically a 3 mmol/L potassium bath is required
 Magnesium supplementation may be needed
R
 Phosphate supplementation is often required (FleetV enema can be added to the dialysate bath if patient is unable to
maintain adequate oral intake)
 A higher dialysate calcium concentrate is recommended (1.5 mmol/L)
 Vitamin D analogues should be prescribed as appropriate if monthly parathyroid hormone levels are high

Anemia
 Target hemoglobin level of 10–11 g/dL
䊊 This target typically requires a significant increase in the erythropoietin stimulating agent dose (double to triple the
prepregnancy dose)
 Maintain adequate iron stores using oral and/or intravenous iron sucrose as required

Dietary Follow-up
 A dietician should monitor the patient’s diet throughout pregnancy
 Typically no dietary restrictions are required, but it is important that a woman’s diet is assessed to ensure she is
eating adequately (protein intake of approximately 1.5–1.8 mg/kg/d)

Obstetric Care
Fetal Monitoring
 Weeks 9 through 13: Screen for nuchal translucency, PAPP-A, bhCG
䊊 CAUTION: The diagnosis of Down syndrome may require additional, more definitive testing, including performing
amniocentesis or Harmony Test (cell-free DNA in maternal blood)
 Weeks 15 through 18: Screen mother for AFP, total hCG, inhibin A, and unconjugated estriol
 Weeks 18 through 20: Perform level II ultrasound to measure cervical length and assess for anomalies
 Week 22: Perform placental ultrasound with Doppler assessment
 Week 26 through delivery:
䊊 Perform weekly ultrasound and biophysical profile
䊊 Provide close follow-up of placental function, fetal growth, and well-being as described above
Diagnosis and management of preeclampsia/eclampsia
䊏 Follow BP records closely for acceleration with weekly physical examinations of volume status
䊏 Perform weekly liver function tests and platelet counts to assess for HELLP syndrome

342 Hemodialysis International 2016; 20:339–348

 HD and pregnancy

Table 2 Continued
䊏 CAUTION: When magnesium sulfate is administered for seizure prophylaxis, reduce the bolus and infusion dose
by approximately half the usual prescribed dose with close monitoring [2-g to 3-g loading dose diluted in 100
mL fluid, administered IV over 15 min, followed by no continuous IV infusion or a significantly reduced rate at
0.5–1.0 g/h. Close monitoring of patient’s neurological and respiratory status as well as frequent monitoring of
levels (at least every 4 h) to target a therapeutic range (4–7 mEq/L or 5–9 mg/dL) is recommended]

Delivery
 Plan induction at or just after 37 wk to ensure all necessary staff and resources are available
 Provide heparin-free dialysis prior to delivery to allow the use of an epidural and limit postpartum bleeding
 Obstetric team will determine mode of delivery; however, vaginal delivery is preferred

Neonatal Care
 Assessment and follow-up by neonatal ICU team in a center equipped to manage preterm babies
 Promote breastfeeding; however, attention should be paid to all medications prescribed to nursing mothers
 Provide lactation-safe antihypertensive agents as required. Options include methyldopa, labetalol, or long-acting
nifedipine. ACEIs, including captopril, quinalapril, and enalapril, are secreted in low amounts and may be used as
necessary. Overly aggressive ultrafiltration may reduce milk supply
 Avoid heparin containing the preservative benzyl alcohol, as it is potentially toxic to premature and low-birth-
weight infants
ACEI 5 angiotensin converting enzyme inhibitor; AFP 5 alpha-fetoprotein; bhCG 5 beta-human chorionic gonadotropin; BP 5 blood
pressure; DNA 5 deoxyribonucleic acid; hCG 5 human chorionic gonadotropin; HD 5 hemodialysis; HELLP 5 hemolysis, elevated liver
enzymes, low platelet count; ICU 5 intensive care unit; IV 5 intravenous; PAPP-A 5 pregnancy-associated plasma protein A.

patient population. Unplanned pregnancies do occur in Renal care

women with ESRD. These women require the same man-
agement strategies described to be expedited along with
careful counseling about all potential risks to allow these
women to make informed decisions with respect to termi-
nation or continuance of the pregnancy.
MANAGEMENT OF THE PREGNANT
ESRD PATIENT
Clinics providing care for pregnant patients with ESRD
require an experienced, collaborative multidisciplinary
team, which ideally includes nephrologists, nephrology
support staff (dieticians, pharmacists, nurses, etc.), and
maternal-fetal medicine specialists or obstetricians who
specialize in high-risk pregnancies. Given the potential
for preterm birth, delivery should occur in a center with
access to a neonatal intensive care unit. Women who live
a distance from such centers should be managed collabo-
ratively with an experienced team, but care close to home
is feasible. Regular team meetings and communication
strategies are vital.
Dialysis intensity
Clearance of urea and other solutes plays a critical role in
the success of an established pregnancy. Before dialysis
was widely implemented, a study reported a direct correla-
tion between fetal mortality and elevated blood urea nitro-
gen (BUN) levels; once BUN concentrations reached
>60 mg/dL (21.4 mmol/L urea), no documented live
births occurred.33 Similarly, in a more recent report that
included 28 pregnant women on HD with 18 surviving
infants, low birth weight (R 5 20.533, P 5 0.016) and
small for gestational age (R 5 2504, P 5 0.023) were neg-
atively correlated with elevated BUN levels.23 Further,
there have been consistently higher live birth rates in
women who initiated dialysis during pregnancy compared
to those who conceived while they were on dialysis, pre-
sumably due to the enhanced clearance from residual kid-
ney function. An analysis of 77 pregnancies recorded in
the ANZDATA registry between 2001 and 2011 also indi-
cated a survival advantage for infants when mothers began
dialysis after conception (91%) compared with those who
became pregnant while on HD (63%; P 5 0.03).34 Women
who conceived while on dialysis also experienced more
early pregnancy losses (<20 wks’ gestation).

Hemodialysis International 2016; 20:339–348 343

Hladunewich and Schatell
Figure 1 Live birth rate, gestational age, and birth weight
by hemodialysis intensity in women with established ESRD.
Adapted from Hladunewich et al.15
These data cumulatively support the use of HD initia-
tion in women with established, advanced chronic kidney
disease, but presently there are no data to guide the
appropriate timing for dialysis initiation in these women,
and there is significant variation in management strategies
globally, including the use of low protein diets to delay
the need to start dialysis in Italy, for example.35 Further
study is needed as initiating HD during pregnancy can be
profoundly difficult, but we currently recommend that
HD should be considered in those women who have a
344
creatinine clearance <20 mL/min or who demonstrate
ongoing progressive loss of kidney function, wherein urea
consistently exceeds 20 mmol/L. Waiting for typical indi-
cations to begin dialysis may jeopardize fetal well-being,
as increased urea can result in polyhydramnios, which
can precipitate preterm delivery or even directly cause
fetal demise. Once initiated, the degree of residual renal
function should determine the level of dialysis intensity
provided by closely following laboratory parameters. It
is critical that pregnant patients are provided increased
dialysis intensity as residual renal function declines.
Pregnancy outcome data from the Toronto Pregnancy
and Kidney Disease (PreKid) Registry compared with data
from the American Registry for Pregnancy in Dialysis
(ARPD) revealed that established ESRD patients in the
Canadian registry, on average, received an extra 32 h of
HD per week than did patients in the ARPD cohort
(43 6 6 vs. 17 6 5 h).15 This increase in dialysis intensity
was accompanied by higher overall live birth rates (83%
vs. 53%; P 5 0.028), increased gestational age (36 vs. 27
wk; P 5 0.002), and higher birth weights (2118 vs.
1748 g; P significant for trend) among Canadian patients
compared with the American patients. Live birth rates for
women receiving more than 20 h of HD per week was just
48%, but this rate increased to 85% when women were
dialyzed more than 36 h/wk (P 5 0.027; Figure 1).15 As
such, clinicians who participate in the PreKid Clinic
now target 36 h or more of HD weekly for pregnant
women with established ESRD without residual renal
function.
Other renal management considerations
Renal management also includes regular medication
reviews; monitoring of vitamins, minerals, electrolytes and
supplementation when necessary; management of anemia;
and management of blood pressure and volume status
(Table 2). Heparin is a safe and effective anticoagulation
therapy that prevents circuit clotting. Typically, no dietary
restrictions are required, and every pregnant woman
should meet with a dietician to ensure she is receiving
adequate caloric and protein intake to meet maternal and
fetal needs. The relationship between maternal calcium
homeostasis and fetal skeletal development is complex,36
but both maternal hypercalcemia and hypocalcemia can
adversely affect the neonate and cause either suppressed
parathyroid activity and neonatal hypocalcemia or activated
parathyroid activity and bone demineralization, respec-
tively. As such, maternal calcium levels should be main-
tained in the normal range. Calcium-based binders and
vitamin D analogs are considered safe in pregnancy and
can be used when necessary, but there are minimal data for
Hemodialysis International 2016; 20:339–348

other commonly used agents including sevelamer and lan-
thanum or the calcimimetics. Intensified HD often requires
a higher potassium and calcium bath as well as phosphate
supplementation if diet proves inadequate. At our center,
we provide phosphate supplementation by adding FleetV
R
enemas to the dialysate. Anemia, presumably due to eryth-
ropoietin resistance, is associated with high transfusion
rates.23,24 Patients with anemia require adequate iron sup-
plementation and double to triple the usual doses of eryth-
ropoietin stimulating agents. Intravenous iron
supplementation is often required. Currently, only iron
sucrose is classified by the US Food and Drug Administra-
tion as a pregnancy Category B drug. In addition to
improvements in obstetric outcomes, intensified dialysis
facilitates volume management and does so more gently
than thrice-weekly HD. As a result, intensified dialysis pro-
vides patients with more stable blood pressure readings
with fewer episodes of hypotension, less interdialytic
weight gain, and reduced doses and/or number of antihy-
pertensive medications used.
Obstetric care
Obstetric follow-up is focused on the usual assessments of
fetal well-being, including the diagnosis of congenital
abnormalities, as well as the early detection of risks for pre-
term delivery and placental dysfunction, which can result
in maternal preeclampsia and fetal growth restriction.
Fetal monitoring
Clinicians should be aware of the potential for false-
positive serum pregnancy tests, as well as the potential to
erroneously diagnose a molar pregnancy, in women with
ESRD due to the role of kidneys in the metabolism and
clearance of human chorionic gonadotropin.14,37,38 Serum
levels of beta-human chorionic gonadotropin can be sig-
nificantly elevated in this patient population. Further, one
must cautiously interpret the results of the first trimester
screening tests for Down syndrome. In women with ESRD,
false-positive screens for Down syndrome can occur due
to elevated serum levels of beta-human chorionic gonado-
tropin39 and pregnancy-associated plasma protein-A
(PAPP-A).40 PAPP-A levels can be further increased by the
heparin used for circuit anticoagulation.41 As such, exer-
cise caution with respect to diagnosis of a molar preg-
nancy or Down syndrome. More definitive testing may be
required, which can include performing an ultrasound
assessment of nuchal thickness, amniocentesis, or nonin-
vasive prenatal testing (e.g., Harmony Prenatal Test for
cell-free DNA in maternal blood42).
Hemodialysis International 2016; 20:339–348
HD and pregnancy
Serial ultrasound examinations are performed to follow
cervical length and determine amniotic fluid volume. Cer-
vical cerclage may be required to treat early cervical
incompetence and prevent preterm birth, which has been
previously noted to occur in this patient population,15 the
cause of which is unclear. Provision of intensified dialysis
offers improved management of uremic toxins and blood
volume, which may decrease the incidence of polyhy-
dramnios and, as a result, decrease the likelihood of pre-
mature delivery and its complications.43
Prevention and management of preeclampsia
Intensive HD improves endothelial function,44 which may
promote improved placental health. However, reported
rates of preeclampsia remain higher in women with
ESRD.15,24 Understanding the cause of worsening hyper-
tension may be challenging in this patient population, but
it is critical to distinguish between volume overload and
superimposed preeclampsia to avoid adverse maternal
and fetal outcomes. Anuria in patients with ESRD com-
plicates the diagnosis of preeclampsia, as neither pro-
teinuria nor impaired renal function can be used as a
means of diagnosis.45 Regular surveillance of other labo-
ratory measures used to test for HELLP (hemolysis, ele-
vated liver enzymes, and low platelets) syndrome along
with regular clinical assessments of volume status are,
therefore, recommended. A clear diagnosis should be
made before proceeding with either increased ultrafiltra-
tion intensity or labor induction.
At approximately 22 wks’ gestation, many centers
perform a placental ultrasound with uterine and umbil-
ical Doppler ultrasound to assess placental size and
morphology, and to quantify pulsatility indices. Abnor-
mal pulsatility indices combined with fetal growth
restriction suggests the diagnosis of preeclampsia.46
Antiangiogenic and angiogenic factor measurements,
including soluble fms-like tyrosine kinase and placental
growth factor, may be used to aid in the diagnosis of
preeclampsia,47 but these assays are not yet widely
available and further study in this patient population is
required.48 Although aspirin has been documented to
decrease the rates of early onset preeclampsia in women
at increased risk,49 it has not been evaluated in preg-
nant patients with ESRD. If magnesium sulfate is used
for preeclampsia-associated seizure prophylaxis, a
lower loading dose, typically without a maintenance
infusion, and careful monitoring are recommended
because magnesium sulfate is cleared renally. (Table 2).
Delivery and postpartum care
Planned induction of labor is recommended at 37 wks’
gestation or just beyond for patients with no maternal or
345
Hladunewich and Schatell
fetal complications. Planned induction allows clinicians to
ensure the patient is well dialyzed and off heparin antico-
agulation in preparation for delivery. Vaginal delivery is
preferred, and Cesarean delivery is recommended only
when there is a clear clinical indication. Advanced plan-
ning and evaluation by the anesthesia and neonatal teams
is recommended, given the complex needs of this patient
population.
Women undergoing dialysis can breastfeed, as desired;
however, overly aggressive ultrafiltration and dehydration
can hamper milk production and should be avoided.
There are restrictions in medication use by women who
choose to breastfeed, as certain medications are incompat-
ible with pregnancy. Conversely, some ACEIs have been
shown not to pass into breast milk,50,51 and may be used
as needed. In postpartum women who choose to breast-
feed, preservative-free heparin is preferred, where avail-
able, to avoid neonatal benzyl alcohol toxicity, especially
in preterm babies.52
SUMMARY
Intensified HD, which is most feasibly delivered in the
home, can improve live birth rates and provide an effec-
tive renal replacement therapy option for young women
who approach ESRD during their reproductive years and
who do not have potential living related kidney donors.
Studies have shown that home HD improves maternal
and fetal outcomes; however, pregnant patients with
ESRD remain at high-risk, and their pregnancies require
meticulous follow-up and care provided by a cooperative
multidisciplinary team.
Manuscript received December 2015; revised March
2016.
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