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Dr Matt Hall Consultant Nephrologist Nottingham University Hospitals February 1 st 2019

Dr Matt Hall Consultant Nephrologist Nottingham University Hospitals February 1 st 2019. Pregnancy and dialysis. Not being pregnant Pregnancy and haemodialysis Pregnancy and peritoneal dialysis Renal Association Guidelines on Pregnancy and Renal Disease (a sneak peak…).

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Dr Matt Hall Consultant Nephrologist Nottingham University Hospitals February 1 st 2019

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  1. Dr Matt Hall Consultant Nephrologist Nottingham University Hospitals February 1st 2019

  2. Pregnancy and dialysis Not being pregnant Pregnancy and haemodialysis Pregnancy and peritoneal dialysis Renal Association Guidelines on Pregnancy and Renal Disease (a sneak peak…)

  3. If a patient receiving dialysis asks me about pregnancy, my approach is: • What time does Mothercare shut? We can go together! • It won’t be easy but we can look at options to give you the best chance of success • It is not safe to think about pregnancy until you’ve had a transplant • Pregnancy and kidney disease are a bad combination and you will not be able to start a family

  4. Young adults with end stage renal disease Want to have children now Never want to have children Want to have children later

  5. Contraception and CKD Safety Effectiveness Thanks to Dr Kate Wiles

  6. The best option for a 19 year old with advanced CKD who does not want to get pregnant is: • Abstinence • Combined Oral Contraceptive Pill • Copper IUCD • Nexplanon progesterone implant • Sterilisation

  7. Contraception and CKD Typical use Perfect use Trussell J. Contraception 2011, 83:379-404

  8. Contraception and CKD COCP – hypertension, sodium retention, glomerular hyperfiltration, VTE risk (nephrotic?), arterial thrombosis Risks Progesterone – decreased BMD?, dyslipidaemia? IUDs – increased risk of failure and infection in transplant recipients Grandi G et al. Contraception 2014,90(5):529-534 Pechere-BertschiA, Maillard M et al. Kidney Int 2003,64(4):1374-1380 Estes CM, Westhoff C. SeminPerinatol 2007,31(6):372-377 Ramhendar T, Byrne P. Contraception 2012, 86(3):288-289

  9. Contraception and CKD Progesterone >40 years? POP Mircera IUD Nexplanon implant Copper IUD Sterilization Cerazette Cerelle Aizea Nacrez

  10. Young adults with end stage renal disease Want to have children now Want to have children later Never want to have children Will I ever be able to have a baby? Wait for a renal transplant with good function and minimal immunosuppression and negligible hypertension

  11. 17 year old. Renal agenesis 2x previous transplants Haemodialysis last 3 years Home HD for the last 12 months 4 x 3hrs per week PRA 100% inc anti-HLA A2 antibodies No live donors identified Not had regular periods since returning to dialysis Will I ever be able to have a baby?

  12. Patients on dialysis are as likely to conceive as patients following renal translantation • True • False

  13. ? 36-57 hrs/week 0-20 hrs/week Barua M, Hladunewich M, Keunun J et al. Clin J Am SocNephrol 2008;3:392/396 Okundaye IB, Abrinko P, Hou S. Am J Kidney Dis 1998; 31(5):974-981

  14. Hall M. Am J Kidney Dis. 2016 Oct;68(4):633-9 Davison J, Bailey DJ. J ObstetGynaecolRes. 2003;29(4):277-233

  15. HD and pregnancy CKD progression

  16. HD and pregnancy p=0.03 p=0.01

  17. Pregnancy and dialysis Conceived January 1970 2 x 12 hours HD /week Delivery at 39+4 weeks 1950g Confortini P, GalantiG, Ancona G, GiongioA, BruschiE, Lorenzini E: Full-term pregnancy and successful delivery in patient on chronic hemodialysis. Proc Eur Dial Transplant Assoc8: 74–80, 1971

  18. Pregnancy and HD 1990 - 2013

  19. Is >37 hours/week necessary for all? Maintenance HD patient or starting in pregnancy Pregnancy confirmed? Diuresis>1000ml/d <1 year HD Or TW<70kg Diuresis<1000ml/d >1 year HD or TW>70kg 6 x 1.5-2 hrs /week 6 x 2-3 hrs /week Severe Hypertension Anorexia, nausea Excessive weight gain Polyhydraminos Pre-dialysis urea>12.5mmol/l Increase session length by 30 minutes

  20. Is >37 hours/week necessary for all? • 50.5% on dialysis prior to conception • Average dialysis time: 15.4 ±4.0 h/week • Successful delivery: 89.2% • Mean fetal weight: 1689 ± 719g • Gestational age at delivery: 35 weeks (range 25-39)

  21. Write a week-to-week care plan For example… • Fetal growth monitoring every 1 – 2 weeks • Liquor volume monitoring every 1 – 2 weeks • CTG monitoring every week from 25 weeks

  22. Renal Association Guidelines Dialysis and pregnancy Women receiving maintenance dialysis before pregnancy Guideline x.x - We recommend that women established on dialysis planning a pregnancy should receive preconception counselling which includes the options of postponing pregnancy until transplantation (when feasible) and long frequent dialysis prior to and during pregnancy (Grade C) Guideline x.x - We recommend that women established on haemodialysis prior to pregnancy should receive long, frequent haemodialysis either in-centre or at home to improve pregnancy outcomes (Grade C) Guideline x.x - We recommend that women receiving haemodialysis during pregnancy should have dialysis dose prescribed accounting for residual renal function, aiming for a pre-dialysis urea <12.5mmol/l (Grade C)

  23. Dialysis and pregnancy INTENSE HD Supplemental HD CKD progression

  24. When do you need to start dialysis in pregnancy? ? “Standard” AKI/CKD indications Signs of fetal compromise Urea > 15mmol/l? 20mmol/l?

  25. Renal Association Guidelines Dialysis and pregnancy Initiating dialysis during pregnancy Guideline x.x - We recommend that haemodialysis should be initiated in pregnancy when the maternal urea concentration is 17-20mmol/L and the risks of preterm delivery outweigh those of dialysis initiation. Gestation, renal function trajectory, fluid balance, biochemistry, and blood pressure control should be considered in addition to maternal urea concentration. (Grade D)

  26. n=6 1950-1960 Maternal baseline urea >20mmol/l Fetal survival – 0% Mackay EV. Aust N Z J ObsetGynecol 1963;3:21 1995-2010 p=0.03 p=0.01

  27. Renal Association Guidelines The guideline committee acknowledge that there are inadequate data to produce evidence-based recommendations on commencing dialysis during pregnancy. However strong support from the UK renal community was received, requesting expert opinion-based practice…

  28. 3. Pregnancy, renal transplantation and dialysis PD and pregnancy …really?

  29. What is your approach to a PD recipient who wants to get pregnant (transplant’s off the cards)? • You can’t conceive if you’re on PD as the eggs get washed out in PD fluid • I’ve looked after plenty of women on PD through pregnancy. You’ll be fine. • PD might not be enough and you might have to switch to HD if you conceive • PD won’t be adequate during pregnancy and we should switch to HD now

  30. PD and pregnancy 1983 First report of CAPD and pregnancy (Cattran) Palmer, then Weston and Roberts, then Henry Tenckhoff introduce the semi-permanent silicone catheter. 1965-1967 G Wegner observed electrolyte and fluid transport across peritoneal membrane. 1877 Wear and team successfully used continuous PD for acute renal failure for the first time. 1936 ISPD founded 1984 Oxford 2018 1977-1979 European units providing PD increased from 0 to 160 1743 Christopher Warwick instilled Bristol water and claret wine into a patient’s peritoneum through a leather pipe. 1964 Boen develops automated peritoneal dialysis system 1918 Cunningham and Blackfan used the peritoneal membrane as a route to fluid administration in severely dehydrated infants. 1923 Georg Ganter treated first patient with uraemia with intraperitoneal saline infusions 1992 First EuroPD meeting

  31. PD and pregnancy 104 patients in case reports and series

  32. PD and pregnancy Systematic review Publications 2000-2014 • 616 pregnancies in women who received HD during pregnancy • 38 pregnancies in women who started PD before pregnancy • 27 started during pregnancy 83% 77% 65% Publication bias! 39% N/A 48-88% Piccoli GB, Minelli F, Versino E et al. NDT 2016;31:1915

  33. PD and pregnancy – practical issues Kids get in the way of everything…

  34. PD and pregnancy – practical issues Delivery (if approaching term) Inadequate clearance or UF Switch to HD Supplement PD with HD

  35. PD and pregnancy – practical issues 9 weeks 12 weeks 28 weeks 24 weeks 19 weeks 4 x 2l over 9h 4 x 2l over 9h 4 x 2l over 9h 4 x 2l over 9h 4 x 2l over 9h 4 x 2l over 9h 5 x 4.5h/week HD 4 x 2l manual exchanges 5 x 4h/week HD 5 x 3h/week HD 3 x 2l manual exchanges 3 x 2l manual exchanges x2/week Delivery at 37+6 weeks 3.005kg Elective LSCS Ross LE, Swift PA, Newbold SM et al. PDI 2016;36(5):575

  36. PD and pregnancy - delivery Skin Subcutaneous tissue Anterior rectus sheath Method Peritoneal membrane Peritoneal cavity Uterine wall Uterine cavity

  37. Renal Association Guidelines Guideline x.x - We recommend that women established on peritoneal dialysis prior to pregnancy should transition to haemodialysis during pregnancy (Grade D)

  38. PD and pregnancy Better pregnancy outcomes with end stage renal disease reported with: Renal transplant, then Haemodialysis Continuation of pregnancy on PD not recommended but could be considered if: Good residual renal function Vascular or social barriers to HD

  39. Summary Almost all women with CKD can consider a pregnancy The role of a nephrologist is to describe the options, possible outcomes and risks… …then support their decision through a pregnancy… …and know your limits

  40. Acknowledgements Pregnancy and CKD RDG Patient Representatives Ms Gemma Haskey Mr Dennis Crane Ms Tess Harris Dr Nadia Sarween Dr Kate Bramham Dr Phil Webster Dr Kate Wiles Dr Ellen Cox Prof Cathy Nelson-Piercy Dr Joyce Popoola Dr Jason Waugh Professor David Edwards Mrs FloriaCheng Mrs Andrea Goodlife Mrs Sue Shaw Nottingham City Hospital Dr Al Ferraro Dr Suzanne Wallace UK-CORD Prof Sue Carr Prof Nigel Brunskill Prof Liz Lightstone Dr Graham Lipkin Dr Clara Day Dr SajedaYoussouf

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