Successful Pregnancy in a Patient on Long-Term Hemodialysis

Abstract

Successful pregnancy is rare in patients who are on long-term dialysis. We describe normal delivery in a young woman who had been on dialysis treatment for more than four years. Case ReportA 38-year-old woman with a long history of proteinuria, microscopic hematuria, and hypertension had first been evaluated in September 1983 by the nephrology service immediately after her tenth delivery, which-was complicated by postpartum hemorrhage. At that time, she was found to have severe renal failure (serum creatinine, 620 μmol/L) with small kidneys. Renal biopsy was not done. Seven months later, she became progressively uremic and maintenance hemodialysis was commenced on a schedule of four hours three times per week using a 1.3 m 2 hollow-fiber dialyzer and glucose bicarbonate dialysate (sodium, 140; potassium, 2; HCO 3 35 mmol/L). She did well, her interdialytic weight gain averaged 1 to 2 kg, and her serum chemistry levels were acceptable. However, packed red cell transfusions were required every 3 to 4 months to control her anemia. Her residual renal function was 1 ml/min. Her blood pressure remained well controlled throughout this time. There was no clinical or radiological evidence of peripheral neuropathy, renal osteodystrophy, or cardiac dysfunction. Her medications included 1-α hydroxy vitamin D3 supplement (0.5 μg daily) and variable doses of aluminum hydroxide. She had had 10 fullterm normal deliveries, the last of which was in September 1983. Her menstrual periods continued to be regular even during dialysis.In October 1988, the patient felt fetal movements and a 20-week pregnancy was confirmed by ultrasound. Her dialysis regimen was increased to four hours, four times a week with no change in the setting, and more frequent packed red blood cell transfusions were required (Figure 1). Her heparin maintenance dose was doubled because of increased clotting of the dialyzers in the third trimester. Her 1-α hydroxy vitamin D3 dosage was increased to 1 μg daily. Her dialysis sessions during pregnancy were fairly stable and her blood pressure continued to be normal. At 32 weeks of pregnancy, shortly after a hemodialysis session, she experienced labor pains and a 1.9-kg male infant was delivered vaginally without complications. The placenta was macroscopically healthy and weighed 500 gm.