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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 19  |  Issue : 6  |  Page : 980-982
Successful pregnancy in end-stage renal disease patient in a sub-urban area of Saudi Arabia


1 ArAr Central Hospital, Northern Borders, Saudi Arabia
2 Post Graduate Center for Studies of Family Medicine, Ministry of Health, Riyadh, Saudi Arabia

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   Abstract 

A 36 years old female with hypertension and chronic kidney disease presented with anemia, nausea, vomiting and progressively rising serum Creatinine. She was found to be 16 weeks pregnant. Hemodialysis was initiated daily; however due to non compliance it remained at thrice weekly of 4 hours per session. She gained a weight during her pregnancy and labor was induced at 36 week and cesarean section performed delivering a healthy baby girl. She continues thrice weekly hemodialysis post partum.

Keywords: Pregnancy, End-Stage Renal Disease, Chronic renal failure, Hemodialysis

How to cite this article:
Imtiaz S, Shams M, Albably SA, Khan AS. Successful pregnancy in end-stage renal disease patient in a sub-urban area of Saudi Arabia. Saudi J Kidney Dis Transpl 2008;19:980-2

How to cite this URL:
Imtiaz S, Shams M, Albably SA, Khan AS. Successful pregnancy in end-stage renal disease patient in a sub-urban area of Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2020 Nov 27];19:980-2. Available from: https://www.sjkdt.org/text.asp?2008/19/6/980/43477

   Introduction Top


The frequency of conception on dialysis ap­pears to be increasing which may reflect im­proved dialysis techniques and beneficial effect of Erythropoietin. The delivery of viable fetus for patients conceiving before starting dialysis is reported to be 73.6% to 80% [1] , whereas after initiation of dialysis it decreases to only 40% to 50% of cases. [2] We report a case of End­Stage Renal Disease (ESRD) with successful pregnancy. This is first ever case of successful outcome of pregnancy in End-Stage Renal Disease (ESRD) patient in any sub urban area of kingdom.


   Case Report Top


A 36-year-old woman was diagnosed to have hypertension and proteinuria about 8 years ago during her last pregnancy persisting post par­tum. She was diagnosed to have chronic kid­ney disease about 5 years ago and was non­compliant with her follow-ups. The patient presented with nausea, vomiting and blood pressure of 170/110 mmHg, and she was found to have anemia and further increase in serum creatinine. She was also found to pregnant in her 16th week. The serum creatinine at the time of presentation was 595 µmol/L (224 µmol/L on her last visit about 4 months ago). Blood pressure was controlled with methyl­dopa 250 mg three times a day. Daily hemodialysis of 4 hours was planned but due to not compliance thrice weekly dialysis was con­tinued. A weekly Kt/V= 5 was maintained in the early period. The hemodialysis was done through right sided subclavian catheter in the first six weeks and later through AV fistula.

Regular follow-up by obstetrician and neph­rologist was ensured. Every two weeks ultra­sonography and monthly cardio-ecography re­mained unremarkable throughout pregnancy. She gained a weight of 13.5kg during her preg­nancy, maintained a good appetite and was asymptomatic during dialysis sessions. Her whole ante-natal period was uneventful and pre dialysis creatinine was kept below 400 mmol/L. The labor was induced at 36 week, and due to poor progression cesarean section was performed delivering a healthy baby girl of 3500 gms. The patient was discharged home 5 days later. She remains on thrice weekly maintenance hemodialysis.


   Discussion Top


A collaborative approach among patients, nephrologists, obstetrician, neonatologist, dia­lysis nurse, and nutritionist is recommended for a successful outcome of a pregnancy.

In general pregnancy in a chronic kidney disease female results in spontaneous abortion in about 56% of patients, 11% patients deve­loped still birth, 14% is neonatal death and 18% with therapeutic abortion, approximately 40% abortion occurs 2nd trimester. [3]

We have also observed two pregnancies ending in spontaneous abortion in our hospital. Hypertension is a common life-threatening problem in all these patients, usually con­trolled by alfa-methyledopa. [4]

Deliveries of viable infants occur at appro­ximately 32 weeks and outcome improves with longer gestation, [5] as in our case a viable infant was delivered at 36 weeks of gestation. Usua­lly the birth weight is on the lower side (1,200 to 1,550 gms at birth) [6] contrary to the weight of our baby 3,500 gms. An increase dose of dialysis with a weekly KT/V of 6 to 8 or dia­lysis 5 to 6 days per week is reported to be beneficial. [7] In our case we achieved this goal only in the second trimester due to noncom­pliance of the patient and continued with a lesser target in the last trimester. This might suggest that even lesser amount of hemodia­lysis could be beneficial in order to achieve a successful pregnancy in chronic kidney disease patients.

In a multivariate analysis of all the factors contributing to the successful; conventional targets of BUN and hemoglobin did not in­fluence fetal outcome. [5]

However, it was observed that number of hours of dialysis positively correlated (R= 0.42 p= 0.035) to gestational age. In our case, 20 hours per week of dialysis in the second tri­mester and later on 12 hrs per week in the last trimester were equally effective. Others have also shown longer hours on hemodialysis as an important factor leading to the pregnancy beyond 28 weeks. [6] Serum creatinine level of 564 µmol/L or less was observed in successful pregnancies. [5] Increased dose of erythropoietin required to maintain hemoglobin level in acceptable range and transfusion are sometime required. [7] Our patient reported with a hemo­globin level of 8 mg/dL and with a dose of 8000 IU s/c after every dialysis and maintained a hemoglobin level around 11 g/dL, she how­ever received one unit of blood due to blood loss during surgery

In conclusion, we speculate that successful pregnancy can be achieved through adequate not intensified hemodialysis, attentive obstetric, nutrition and nephrology care.

 
   References Top

1.Bagon JA, Vernaeve H, De Muylder X, Lafontaine JJ, Martens J, Van Roost G. Preg­nancy and dialysis. Am J Kidney Dis 1998; 31(5):756-65.  Back to cited text no. 1    
2.Okunday I, Abrinko P, Hou S. Registry of pregnancy in dialysis patients. Am J Kidney Dis 1998;31(5):766-73.  Back to cited text no. 2    
3.Toma H, Tanbe K, Tocomumoto T, Kobayashi C, Yagisawa T. Pregnancy in women receiving renal dialysis or transplantation in Japan: a nationwide survey. Nephrol Dial Transplant 1999;14(6):1511-6.  Back to cited text no. 3    
4.Reddy SS, Holley JL. Management of the pregnant chronic dialysis patient. Adv Chronic Kidney Dis 2007;14(2):146-55.  Back to cited text no. 4    
5.Chen WS, Oklnn, Kjellstrad CM. Pregnancy in chronic dialysis: a review and analysis of the literature. Int J Artif Organ 1998;21(5):259-68.  Back to cited text no. 5    
6.Souqiyyah MZ, Huraib SO, Saleh AG, Awad S. Pregnancy in chronic renal hemodialysis patient in Kingdom of Saudi Arabia. Am J Kidney Dis 1992;19(3):255-8.  Back to cited text no. 6    
7.Maruyama H, Shimada H, Obayashi H, et al. Requiring higher doses of erythropoietin suggests pregnancy in hemodialysis patients. Nephron 1998;79(4):413-9.  Back to cited text no. 7    

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Correspondence Address:
Salman Imtiaz
P.O. Box 1348 ArAr (Northern Zone), Ministry of Health
Saudi Arabia
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PMID: 18974589

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    Abstract
    Introduction
    Case Report
    Discussion
    References
 

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