A successful term pregnancy using in-center intensive quotidian hemodialysis

Serum urea acid and urea nitrogen levels are risk factors for maternal and fetal outcomes of pregnancy: a retrospective cohort study

BACKGROUND

In recent years, results on the association between serum uric acid (UA) and pregnancy outcomes have been inconsistent, and the association between urea nitrogen (UN) and adverse pregnancy outcomes in normal pregnant women has not been reported. Thus, we examined the association of UA and UN levels during gestation with the risk of adverse pregnancy outcomes in a relatively large population.

METHODS

A total of 1602 singleton mothers from Union Shenzhen Hospital of Huazhong University of Science and Technology at January 2015 to December 2018 were included. Both UA and UN levels were collected and measured during the second (16-18th week) and third (28-30th week) trimesters of gestation respectively. Statistical analysis was performed using multivariate logistic regression.

RESULTS

After adjustment, the highest quartile of UA in the third trimester increased the risk of premature rupture of membranes (PROM) and small for gestational age infants (SGA) by 48% (odds ratio [OR]: 1.48, 95% confidence interval [CI]: 1.04-2.10) and 99% (95% CI: 1.01-3.89) compared to those in the lowest quartile. The adjusted OR (95% CI) in the highest quartile of UN for the risk of SGA was 2.18 (95% CI: 1.16-4.13) and 2.29 (95% CI: 1.20-4.36) in the second and third trimester, respectively. In the second trimester, when UA and UN levels were both in the highest quartile, the adjusted OR (95% CI) for the risk of SGA was 2.51 (95% CI: 1.23-5.10). In the third trimester, when the group 1 (both indicators are in the first quartile) was compared, the adjusted ORs (95% CI) for the risk of SGA were 1.98 (95% CI: 1.22-3.23) and 2.31 (95% CI: 1.16-4.61) for group 2 (UA or UN is in the second or third quartile) and group 3 (both indicators are in the fourth quartile), respectively.

CONCLUSIONS

Higher UA and UN levels increased the risk of maternal and fetal outcomes. The simultaneous elevation of UA and UN levels was a high-risk factors for the development of SGA, regardless of whether they were in the second or third trimester.

Renal Association Clinical Practice Guideline on Haemodialysis

This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.

[Pregnancies in hemodialysis and in patients with end-stage chronic kidney disease : epidemiology, management and prognosis]

Pregnancy in patients presenting end-stage renal disease is rare and there are currently no recommendations for the management of these patients. In hemodialysis patients, reduced fertility and medical reluctance limit the frequency of pregnancies. Although the prognosis has significantly improved, a significant risk for unfavorable maternal (pre-eclampsia, eclampsia) and fetal (pre-term birth, intrauterine growth restriction, still death) outcome still remains. Increasing dialysis dose with the initiation of daily dialysis sessions, early adaptation of medications to limit teratogenicity and management of chronic kidney disease complications (anemia, hypertension) are required. A tight coordination between nephrologists and obstetricians remains the central pillar of the care. In peritoneal dialysis, pregnancy is also possible with modification of the exchange protocol and reducing volumes.

Pregnancy outcomes according to dialysis commencing before or after conception in women with ESRD

BACKGROUND AND OBJECTIVES

Pregnancy in ESRD is rare and poses substantial risk for mother and baby. This study describes a large series of pregnancies in women undergoing long-term dialysis treatment and reviews maternal and fetal outcomes. Specifically, women who had conceived before and after starting long-term dialysis are compared.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENT

All pregnancies reported to the Australian and New Zealand Dialysis and Transplantation Registry from 2001 to 2011 (n=77), following the introduction of specific parenthood data collection, were analyzed.

RESULTS

Between 2001 and 2011, there were 77 pregnancies among 73 women. Of these, 53 pregnancies were in women who conceived after long-term dialysis was established and 24 pregnancies occurred before dialysis began. The overall live birth rate (after exclusion of elective terminations) was 73%. In pregnancies reaching 20 weeks gestation, the live birth rate was 82%. Women who conceived before dialysis commenced had significantly higher live birth rates (91% versus 63%; P=0.03), but infants had similar birthweight and gestational age. This difference in live birth rate was primarily due to higher rates of early pregnancy loss before 20 weeks in women who conceived after dialysis was established. In pregnancies that reached 20 weeks or more, the live birth rate was higher in women with conception before dialysis commenced (91% versus 76%; P=0.28). Overall, the median gestational age was 33.8 weeks (interquartile range, 30.6-37.6 weeks) and median birthweight was 1750 g (interquartile range, 1130-2417 g). More than 40% of pregnancies reached >34 weeks' gestation; prematurity at <28 weeks was 11.4% and 28-day neonatal survival rate was 98%.

CONCLUSIONS

Women with kidney disease who start long-term dialysis after conception have superior live birth rates compared with those already established on dialysis at the time of conception, although these pregnancies remain high risk.

Home haemodialysis dose: how much of a good thing?

BACKGROUND

Home dialysis (peritoneal or haemodialysis) in any reasonable guise offers potential benefits compared with in-centre dialysis. Benefits may be overtly patient centred (independence, quality of life), outcome oriented (survival, resolution of left ventricular hypertrophy) or resource friendly (savings on staff costs). The priority placed on each of these areas is likely to vary from patient to patient, and possibly provider to provider. This is the one strength of home haemodialysis (HHD) rather than being viewed as a weakness, as it can offer different benefits to different people. Intuitively, more haemodialysis is better than less, and this is most realistically achieved at home. Indications are that both long nocturnal dialysis and short daily dialysis can offer real objective benefits.

LITERATURE REVIEW

Critics argue correctly that there is a paucity of robust randomised controlled study data. The complexity of HHD regimens and practice and in-homogeneity of patients means such firm data are unlikely to be forthcoming. However, the positive reports both subjective and objective of patients dialysing at home, and results from the available research suggest that advantages may be seen purely with changing the location of dialysis to home, and independently with enhancing dialysis schedules.

CONCLUSION

The logical conclusion is that patients undertaking haemodialysis at home should have at least the recommended minimum of four hours three times per week (or equivalent), preferably avoiding the long inter-dialytic interval, but beyond that rigid adherence to a schedule as dogma should be subjugated to patient choice and flexibility, albeit by prior agreement with supervising medical and nursing staff.