Sunday, January 8, 2017

In the NEWS: US Nephrologists, dialysis and pregnancy

Getty Images/iStockphoto/ThinkStockPregnancy occurs among 1–7% of women on chronic dialysis. Data on how dialysis is provided in ESRD patients who get pregnant in the US is lacking. A recent survey published reveals the latest update on this topic. 

While the response rate is small, the information might be important. Limited providers might have this experience of providing for dialysis for the pregnant patient. Of the respondents, 45% had cared for pregnant females on HD and 78% of pregnancies resulted in live births. In 44% of the pregnancies a diagnosis of preeclampsia was made. There were no maternal deaths. Nephrologists most commonly prescribe 4–4.5 h of HD 6 days/week for pregnant women on dialysis. More dialysis time is associated with better volume and electrolyte control. The frequency of preterm delivery and intrauterine growth restriction tends to correlate with BUN levels. There is an inverse association between BUN level and birthweight and adverse fetal outcome, with more favorable outcomes when the serum urea level is <75 mg/dL. The survey shows that most US nephrologists target a BUN of <50 mg/dL (66%) and 21% aim for a target predialysis BUN of <20 mg/dL. Intensive dialysis is a necessary important finding that is now becoming norm for patients who are pregnant.  Both maternal and fetal outcomes have improved.

What was interesting in the study was "
Women dialyzed cumulatively for >20 h/week were 2.2 times more likely to develop preeclampsia than those who received ≤20 h of HD per week."

Why would that be?.  The authors think that it might be for two reasons: increased hours on HD leading to more vasoconstriction and tighter volume control leading to pre eclampsia. Also since this was a survey, the diagnosis of preeclampsia was dependent on the nephrologist recognizing it and perhaps a "diagnosis" labeling problem. 

Pregnancy on dialysis is becoming frequently encountered, pregnancy care should be part of the health maintenance plan of women of childbearing age on dialysis. OB-Nephrology should be considered a sub field in Nephrology and should become part of academic centers as a career paths for nephrologists and training of fellows. 

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