PREGNANCY IN END STAGE RENAL DISEASE PATIENTS AND

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PREGNANCY IN END STAGE RENAL DISEASE PATIENTS AND TREATMENT WITH PERITONEAL DIALYSIS:

PREGNANCY IN END STAGE RENAL DISEASE PATIENTS AND TREATMENT WITH PERITONEAL DIALYSIS Dr. Ristua Butar-Butar, Sp.PD

Definition:

Definition Also known as End-Stage Renal Failure (ESRF), is a progressive deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia (retention of urea and other nitrogenous wastes in the blood). decreased kidney glomerular filtration rate (GFR) of <60 mL/min/1.73 m2 for 3 or more months

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CKD stage GFR (ml/min/1.73m 2 ) Description 1 >90 Normal renal function but other evidence of organ damage* 2 60-89 Mild reduction in renal function with other evidence of organ damage* 3 30-59 Moderately reduced GFR 4 15-29 Severely reduced GFR 5 <15 End stage, or approaching, end stage renal failure * Structural (eg APCKD), functional (eg proteinuria) or biopsy proven GN

Offer testing for CKD:

Offer testing for CKD Diabetes HTN CV disease: IHD, CHF, PVD, CVD Structural disease, calculi or BPH Multisystem eg SLE FHx CKD 5 or hereditary kidney disease Nephrotoxins (CNIs or ACE inhibitors) Opportunistic detection of h ema turia or p io uria

What is Dialysis?:

What is Dialysis? Dialysis is a type of renal replacement therapy which is used to provide artificial replacement for lost kidney function due to acute or chronic kidney failure May be used for very sick clients who have suddenly lost kidney function May be used for stable clients who have permanently lost kidney function Healthy kidneys remove waste products (potassium, acid, urea) from the blood and they also remove excess fluid in the form of urine

2 Main Types of Dialysis:

2 Main Types of Dialysis Hemodialysis Peritoneal Dialysis Adapted from National Institute of Diabetes and Digestive and Kidney Diseases

Introduction:

Introduction The first case of a pregnant end-stage renal disease (ESRD) patient on hemodialysis (HD) resulting in full-term pregnancy occurred in 1971 in a 35-year old some reports  estimated frequency of conception in patients on dialysis  within a range as variable as 1.4% per year in Saudi Arabia to 0.5% in the United States.

Introduction:

Introduction H igher conception rate in HD over PD (2.4% versus 1.1%) In terms of the proper treatment  substitution of kidney function  generally determined that the threshold to begin dialysis  creatinine level between 3.5 and 4 mg/ dL and blood urea nitrogen level 50 mg/ dL and/or metabolic acidosis and/or fluid overload

Introduction:

Introduction S pecific obstetric complications (occur in dialysis patients), including polyhydramnios (PHA), preterm labor (PT), hypertension (HTN), intra-uterine growth retardation (IUGR)

Case:

Case 28 y/o AA woman . Bilateral Nephrolithiasis since the age 7, abandoned treatment for 2o years P regnancy of 16 weeks with renal disease blood pressure 110/70 mmHg, heart rate 80/minute, temperature 36.5°C, weight 45 kg, height 162 cm

Nephrologic care ::

Nephrologic care : Diet calculated for proteins 1.5 g/kg body weight, phosphorus 800 mg/day, 45 calories per kg body weight and total liquids 1500 cc/day. PD dose was set to six exchanges per day, five with 1500 mL 1.5% PD solution with a dwell time of 3 hours, and one 1500 mL exchange of 4.25% PD solution with a dwell time of 4 hours, a weekly Kt/V being obtained of 1.9 and a weekly creatinine clearance of 58 L. Mean urea and creatinine levels during pregnancy were 100 mg/ dL and 7 mg/ dL respectively. She also had residual urinary volume of 1.2 L daily.

....:

.... Treatment for anemia was based on erythropoietin 3 times per week plus parenteral administration of iron once per week, which resulted in a hemoglobin value of 11.5 g/ dL at the end of the pregnancy.

....:

.... The main complications during the pregnancy were a gastrointestinal feeling of fullness during dialysis and urinary tract infections on four occasions, documented by positive urine culture for E. coli in the four cases. She never had signs of peritonitis or infection of the tunnel, or catheter dysfunction. Polyhydramnios was documented by obstetrical ultrasounds. Sh e was normotensive without medication.

CASE 2:

CASE 2 A 20-year-old primigravid patient with pregnancy of 27 weeks was admitted. She came for pregnancy control for the first time 17 July 2005 and was found to be azotemic She had blood pressure 120/80 mmHg, heart rate 79/minute, temperature 36°C, weight 74 kg, height 155 cm; globoseform abdomen at the expense of a 2 cm subcutaneous fat layer, gravid uterus with pubis fundus diameter of 26 cm, and no edema of the limbs.

The Nephrology Service:

The Nephrology Service Diet calculated for calories 30 kcal/kg/day, proteins 1.3 g/kg/day, lipids under 30% polyunsaturated, sodium chloride 3 g, potassium 2 g, phosphorus 800 mg, free liquids. Strict blood pressure monitoring. Vitamin supplementation. For treatment of the anemia, intravenous iron dextran and erythropoietin 3 times per week. Mineral metabolism: calcium carbonate 1 g with each meal, and calcitriol 0.25 mg/day. Surgical placement of a Tenckhoff catheter by the Transplant Surgery Service.

DISCUSSION:

DISCUSSION Pregnancy in patients with ESRD is infrequent. The understanding of the physiopathology of infertility in this type of patient is that this infrequency is due classically to anovulation and hyperprolactinemia being responsible for the oligomenorrhea seen in female patients on dialysis Another factor mentioned is the reduced libido of these patients, which, according to some authors, is caused by alterations in human chorionic gonadotropin pulses due to increased endorphins, which in turn are due to reduction of renal clearance POSSIBILITIES OF PREGNANCY

CONCEPTION RATE AND ITS OUTCOME IN DIALYSIS PATIENTS:

CONCEPTION RATE AND ITS OUTCOME IN DIALYSIS PATIENTS the United States Renal Data Systems, in 1992, of 12992 women under 44 years of age who were receiving dialysis, there were 344 pregnancies (2.6%); of these, 209 women were already receiving dialysis, 58 women became pregnant before beginning dialysis, and for 77 of the women, onset of dialysis was unknown. Of these total pregnancies, 42% were full term, 32% had spontaneous miscarriage, 10.5% were aborted therapeutically, 7.5% were neonatal death, and 6% stillborn (8–11).

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A publication in 1998 by the Nephrology Department of Rush Presbyterian Hospital in Chicago, Illinois, established that, in a 4-year period between 1992 and 1995, of 6230 women between the ages of 14 and 44 years (4531 on HD and 1699 on PD) in 930 dialysis centers, only 128 (2%) managed to become pregnant 109 (2.4%) on HD and 19 (1.1%) on PD. Of these 128 patients, 48 (37.5%) who became pregnant after starting substitution therapy managed to conclude the pregnancy successfully, as did 72.6% of the 57 patients who began dialysis during their pregnancy

CHOICE OF RENAL REPLACEMENT THERAPY:

CHOICE OF RENAL REPLACEMENT THERAPY In our case and considering the scant experience in the management of this type of patient, PD was preferred With the first patient, we chose the renal function substitution method that we use most often in the Institution and with which we have more experience in patient management. In the second patient, the choice was based on the successful t reatment of the first patient

DIALYSIS MANAGEMENT AND COMPLICATIONS:

DIALYSIS MANAGEMENT AND COMPLICATIONS

Complications:

Complications Finally, both infants were female; only one was premature with low weight and the complication in the first infant was not directly related to ESRD or to its treatment with automated PD.

CONCLUSIONS:

CONCLUSIONS P eritoneal dialysis is an acceptable therapeutic option for pregnant patients and their fetuses

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