MO828INTENSIFIED TREATMENT FOR PREGNANCY IN HEMODIALYSIS PATIENTS, ANALYSIS OF 13 CASES: IS THERE A GENDER ADVANTAGE?

Background and Aims Pregnancy in dialysis patients is rare but challenging for nephrologists and obstetricians, because pregnancy has a significant maternal and fetal risk in these patients. Although intensified hemodialysis is effective to achieve favorable clinical outcomes, the evidence concerning reliable parameters for the optimal dialysis prescription is scarce. Herein, we report the management on hemodialysis and outcome of pregnancies occurring in the B. Braun dialysis network in Russia. Method We performed retrospective analysis of all pregnancy cases in B. Braun dialysis chain in Russia from 2013 to 2020. Cases were reported by the involved Renal Care Centers by a common questionnaire. All patients were treated with B. Braun Dialog+, AV set Dialog +, SolCart bicarbonate cartridge and Xevonta dialyzers. Results 13 pregnancies were reported, all achieved without infertility treatment: 1 was interrupted by voluntary termination of pregnancy, 9 resulted with living birth (6 females and 3 males) after a mean of 24 gestational weeks (7 cesarean and 2 vaginal deliveries), 2 with stillbirth and 1 with spontaneous abortion after 8 gestational weeks. Mothers with positive pregnancy outcome were significantly younger (27.9±5.1 vs. 36.3±5.6 years), without differences in dialysis vintage, previous successful or unsuccessful pregnancies and during follow-up blood pressure was well controlled. Females newborns had borderline significant greater body weight (1.9±0.6 vs. 1.1±0.1 kg, p=0.076). 5 newborns had respiratory distress syndrome, 1 jaundice. Conclusion Prompt increase of treatment frequency and time on high-flux/HDF dialysis were associated with successful pregnancy outcome. Considering that cardiovascular system and endogenous metabolism dynamically alter during pregnancy, various clinical parameters, i.e. body weight and blood pressure, should be closely monitored to modify dialysis settings accordingly. Female gender of the newborn seems to be associated with a better outcome. This study shows the safety of high-flux hemodialysis and hemodiafiltration treatments in pregnancy and the benefit of enhanced prescription in dialysis time and frequency. Acknowledgement The authors express their gratitude to the entire medical multidisciplinary team from B. Braun Russia Renal Care Centers and other local medical institutions directly and indirectly involved in the treatment of each case described.

Intensified hemodialysis for complicated pregnancy in a primigravida with advanced maternal age: a case report with literature review focusing on appropriate hemodialysis management during pregnancy

Background Pregnancy in dialysis patients is rare but challenging both for nephrologists and obstetricians. Although intensified hemodialysis is effective to achieve favorable clinical outcomes in this clinical setting, the evidence concerning reliable parameters for the optimal dialysis prescription is scarce. Herein, we report a case of a primigravida with advanced maternal age who underwent a normal spontaneous vaginal delivery at full term managed by intensified hemodialysis, and discuss reliable indicators of the appropriate dialysis prescription. Case presentation A 39-year-old primigravida with end-stage renal disease was referred to our department for hemodialysis management during pregnancy. She had a history of multiple gynecologic disorders, including cervical dysplasia, right tubal ectopic pregnancy and spontaneous abortion; consequently, she conceived through in vitro fertilization and embryo transfer. After pregnancy was confirmed, an intensified hemodialysis schedule with weekly duration of 36 hours was employed to prevent volume overload and the accumulation of hyperosmotic substances. Utilizing maternal blood pressure, plasma atrial natriuretic peptide levels and fetal development as indicators of volume status, we incremented her dry weight by 300–400 g per week in the first and second trimester and 100–200 g per week in the third trimester, respectively. Serum urea nitrogen levels were persistently maintained below 50 mg/dL. Throughout pregnancy, fetal growth and development were within normal limits. At 38 weeks and 3 days of gestation, she delivered a healthy child vaginally without complications. To date, the child’s development has been normal, both physically and mentally. Conclusions Pregnancy in dialysis patients with advanced age that leads to a normal childbirth is exceptionally rare. Our case is the hemodialysis patient with the most advanced age who achieves a normal spontaneous vaginal delivery at full term. Considering that cardiovascular system and endogenous metabolism dynamically alter during pregnancy, various clinical parameters should be closely monitored to modify dialysis settings accordingly. Of note, our case suggests that plasma atrial natriuretic peptide level is a useful parameter for the appropriate dry weight. Intensified hemodialysis is an effective and reliable measure that can achieve normal pregnancy in dialysis patients, even in a primigravida with advanced maternal age.

The Impact of Intensified Hemodialysis on Pruritus in an End Stage Renal Disease Patient with Biliary Ductopenia

We report a unique observation characterized by the coexistence of idiopathic adulthood ductopenia (IAD), a rare cholestatic disease, and end stage renal failure treated by conventional hemodialysis in a patient awaiting double renal and liver transplantation. As pruritus gradually worsened, we hypothesized that intensified dialysis could alleviate the symptoms. Conventional hemodialysis following 3 hours/3 times a week regimen was initiated in December 2013. Due to increasing pruritus not responding to standard medical therapy, intensified hemodialysis following 2.5 hours/5 times a week regimen was started in May 2014. During two weeks, a temporary decrease in bilirubin levels was observed. No major changes on other liver function tests and inflammatory markers occurred. Nevertheless, a persistent improvement on pruritus and general wellbeing was obtained during the four weeks’ study period. The pathogenesis of itch encompasses multiple factors, and, in our case, both uremic and cholestatic pruritus are involved, although the latter is likely to account for a greater proportion. By improving itch intensity, through better clearance of uremic and cholestatic toxins which we detail further, intensive dialysis appears to be an acceptable short-term method for patients with hepatic cholestasis and moderate pruritus not responding to conventional therapy. Additional studies are needed to assess and differentiate precisely factors contributing to pruritus of both origins.