Pregnancy in Advanced CKD and End-stage Renal Disease
Pregnancy in Advanced CKD and End-stage Renal Disease
Purpose of review This article reviews the available literature about the incidence, outcomes, and the management of pregnancy in women with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) who require renal replacement therapy.
Recent findings Pregnancy in women with advanced CKD and ESRD can result in serious adverse maternal and fetal outcomes, but improved outcomes have been noted in recent years, likely secondary to intensified dialysis regimens. More intensive dialysis allows for the gentle removal of water, solutes, and uremic toxins, which theoretically results in near-normal maternal renal physiology, an improvement in placental blood flow, and therefore a better environment for fetal growth and development. As management remains complex, a close joint collaboration between the high-risk obstetrical team and nephrology is essential.
Summary Pregnancy on dialysis is becoming a viable option for women with advanced CKD and ESRD who do not have immediate access to transplantation.
Pregnancy becomes increasingly challenging as young women progress through the stages of chronic kidney disease (CKD). Potential untoward outcomes include the progression of underlying renal dysfunction, worsening of urine protein, and hypertension, as well as untoward fetal outcomes including intrauterine growth restriction and preterm delivery. It is known that the risk increases with the degree of renal insufficiency and is further heightened by coexisting hypertension and proteinuria. As such, pregnancies occurring in young women with advanced renal insufficiency (CKD stages 4 and 5) can result in significantly compromised maternal and fetal well-being.
Furthermore, advanced CKD is also a powerful form of contraception. As a young woman's kidneys fail, a number of hormonal changes compromise fertility. Most female patients on dialysis suffer from amenorrhea, whereas those who continue to menstruate tend to have anovulatory cycles. Sexual dysfunction is also commonly encountered in advanced CKD patients, primarily due to decreased sexual interest likely as a result of the cumulative effects of depression, fatigue, medication side-effects, and altered body image, all of which are common in patients with end-stage renal disease (ESRD). As such, young women who approach ESRD during their reproductive years often miss the opportunity to have a child unless kidney transplantation is imminent, which remains the best renal replacement therapy for ESRD patients, including the subgroup contemplating pregnancy. Compared with women on dialysis, transplant recipients have restored fertility and a higher incidence of successful pregnancies with fewer complications. However, long transplant waiting times, in particular, for young women with a limited reproductive window, may prevent this as a viable strategy for having a child.
Dialysis, therefore, remains the most readily available method of renal replacement therapy, but the literature concerning pregnancy while on dialysis is generally scarce, and it has long been considered to be challenging to manage pregnancy when it occurs on dialysis. Recently, intensive hemodialysis has been shown to improve fertility as well as pregnancy outcomes, and may prove a therapeutic strategy for young women with advanced CKD and ESRD. In this article, we will review pregnancy incidence and outcomes among women on dialysis and incorporate our experience and recommendations for treating this vulnerable group of young women. Finally, we will discuss potential concerns that require ongoing multicenter collaboration to better understand risk and management strategies.
Abstract and Introduction
Abstract
Purpose of review This article reviews the available literature about the incidence, outcomes, and the management of pregnancy in women with advanced chronic kidney disease (CKD) and end-stage renal disease (ESRD) who require renal replacement therapy.
Recent findings Pregnancy in women with advanced CKD and ESRD can result in serious adverse maternal and fetal outcomes, but improved outcomes have been noted in recent years, likely secondary to intensified dialysis regimens. More intensive dialysis allows for the gentle removal of water, solutes, and uremic toxins, which theoretically results in near-normal maternal renal physiology, an improvement in placental blood flow, and therefore a better environment for fetal growth and development. As management remains complex, a close joint collaboration between the high-risk obstetrical team and nephrology is essential.
Summary Pregnancy on dialysis is becoming a viable option for women with advanced CKD and ESRD who do not have immediate access to transplantation.
Introduction
Pregnancy becomes increasingly challenging as young women progress through the stages of chronic kidney disease (CKD). Potential untoward outcomes include the progression of underlying renal dysfunction, worsening of urine protein, and hypertension, as well as untoward fetal outcomes including intrauterine growth restriction and preterm delivery. It is known that the risk increases with the degree of renal insufficiency and is further heightened by coexisting hypertension and proteinuria. As such, pregnancies occurring in young women with advanced renal insufficiency (CKD stages 4 and 5) can result in significantly compromised maternal and fetal well-being.
Furthermore, advanced CKD is also a powerful form of contraception. As a young woman's kidneys fail, a number of hormonal changes compromise fertility. Most female patients on dialysis suffer from amenorrhea, whereas those who continue to menstruate tend to have anovulatory cycles. Sexual dysfunction is also commonly encountered in advanced CKD patients, primarily due to decreased sexual interest likely as a result of the cumulative effects of depression, fatigue, medication side-effects, and altered body image, all of which are common in patients with end-stage renal disease (ESRD). As such, young women who approach ESRD during their reproductive years often miss the opportunity to have a child unless kidney transplantation is imminent, which remains the best renal replacement therapy for ESRD patients, including the subgroup contemplating pregnancy. Compared with women on dialysis, transplant recipients have restored fertility and a higher incidence of successful pregnancies with fewer complications. However, long transplant waiting times, in particular, for young women with a limited reproductive window, may prevent this as a viable strategy for having a child.
Dialysis, therefore, remains the most readily available method of renal replacement therapy, but the literature concerning pregnancy while on dialysis is generally scarce, and it has long been considered to be challenging to manage pregnancy when it occurs on dialysis. Recently, intensive hemodialysis has been shown to improve fertility as well as pregnancy outcomes, and may prove a therapeutic strategy for young women with advanced CKD and ESRD. In this article, we will review pregnancy incidence and outcomes among women on dialysis and incorporate our experience and recommendations for treating this vulnerable group of young women. Finally, we will discuss potential concerns that require ongoing multicenter collaboration to better understand risk and management strategies.
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