Chronic kidney disease stage 5 with superimposed preeclampsia for caesarean section: Anaesthetic challenges

Dear Editor,

Pregnancy with chronic kidney disease (CKD) is uncommon (<1%) and is associated with maternal and foetal morbidity including end-organ dysfunction, particularly when complicated by superimposed preeclampsia.[1,2] The anaesthetic management is challenging due to altered pharmacokinetics, fluid balance concerns, platelet dysfunction, and haemodynamic instability.[3,4] Perioperative goals include maintaining maternal perfusion, uteroplacental blood flow, perioperative haemodynamics, minimising fluid overload, and providing effective postoperative analgesia.[3,4,5]

A 23-year-old primigravida (weight 65 kg, body mass index 21.8 kg/m²) at 33 weeks and 6 days of gestation was scheduled for elective caesarean delivery. She had regular antenatal checkups elsewhere and had anaemia with haemoglobin (Hb) of 6 gm/dl in the second trimester, treated with oral iron and four packed red blood cells (PRBCs). At 24 weeks of gestation, she was referred to our institution with persistent anaemia, elevated blood pressure (BP) of 150/100 mmHg, and worsening renal function with blood urea nitrogen (BUN) 155 mg/dl, serum creatinine (SC) 5.0 mg/dl, proteinuria 1.27 g/24 hours, and estimated glomerular filtration rate (eGFR) 12 mL/min/1.73 m², consistent with stage V CKD. Ultrasonography revealed bilaterally contracted kidneys with increased cortical echogenicity. New-onset hypertension along with proteinuria confirmed superimposed preeclampsia, and she was managed with oral labetalol 100 mg thrice a day. Haemodialysis was performed along with administration of 2 units of PRBCs, followed by alternate-day renal function testing and anti-hypertensive therapy.

At 29 weeks, she developed dyspnoea with bilateral basal crepitations secondary to fluid overload with BUN levels rising to 220 mg/dl and SC 5 mg/dl, for which she underwent two sessions of haemodialysis with two PRBC transfusions. At 33 weeks, rising BUN (158 mg/dL) and SC (4.8 mg/dL) necessitated two more dialysis sessions on alternate days and transfusion of two more units of PRBCs.

Four days prior to the elective caesarean section, she underwent dialysis. On table, her BP was 142/90 mmHg, with no signs of fluid overload. Her BUN was 119 mg/dL, SC 4.8 mg/dL, and serum potassium 4.32 mEq/L. Arterial blood gas analysis revealed a potential of hydrogen (pH) of 7.45, a partial pressure of carbon dioxide (PaCO₂) of 36.8 mmHg, a partial pressure of oxygen (PaO₂) of 74.5 mmHg, bicarbonate (HCO₃^–) 22 mEq/L, and arterial oxygen saturation (SaO₂) 98%. The international normalised ratio was 1.0, and the platelet count was normal.

Considering the risks associated with general anaesthesia—difficult airway, exaggerated hypertensive responses, altered drug clearance, delayed recovery, and fluid overload (due to impaired renal excretion and pregnancy-related plasma volume expansion)—a regional anaesthetic technique was preferred.[3,4] Intraoperative monitoring included continuous electrocardiography, non-invasive blood pressure, peripheral oxygen saturation (SpO₂), and urine output. Spinal anaesthesia was administered at the L3–L4 interspace using 1.5 mL of 0.5% hyperbaric bupivacaine with fentanyl 25 µg, achieving a T6 sensory level.[4] Spinal-induced hypotension was managed with intermittent boluses of intravenous (IV) phenylephrine (50 µg each), titrated over a period of 20 minutes, with a total cumulative dose of 300 µg.[6] 700 ml fluid was given over 1 hour (500 ml ringer lactate and 200 ml 0.9% normal saline).[4] Urine output was 100 ml, and the estimated blood loss was 300 ml.

A 1500 g neonate was delivered with Apgar scores of 7 and 9 at 1 and 5 minutes, respectively. Oxytocin (15 IU in 100 ml normal saline) was administered as slow IV infusion over 20 minutes. The surgery lasted for 1 hour and was uneventful. Bilateral ultrasound-guided transversus abdominis plane (TAP) blocks (15 mL of 0.25% bupivacaine per side) were administered for postoperative analgesia.[5] IV paracetamol 1 gm TID (three times a day) was continued postoperatively, and she remained comfortable throughout.

Postoperatively, she was managed in the intensive care unit with monitoring of haemodynamics and serial renal function tests. The urine output was 1.5–2 L/day without signs of uraemia or fluid overload. Deep vein thrombosis prophylaxis with compression stockings was given and early ambulation was done. She was discharged on the 7^th postoperative day with BUN 98 mg/dL and SC 4.0 mg/dL, without requiring dialysis and advised to undergo regular nephrology follow-up.

Multi-disciplinary planning, pre-operative optimisation, and individualised anaesthetic management in parturients with advanced CKD requiring haemodialysis are imperative for the successful management of such cases.

Declaration of Patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient consented to the images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Author contributions

VS: Concept, drafting the article, revising intellectual content, editing, final approval, agreement to be accountable for all aspects of the work. MT: Concept, drafting of article, editing, revising it critically for important intellectual content. TN: Drafting, revising intellectual content. JG: Drafting and revising intellectual content. SP: Drafting and revising intellectual content.

Study data availability

Single case - details available with the authours.

Disclosure of use of artificial intelligence (AI)-assistive or generative tools

AI-assistive or generative tools were not used for this manuscript.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.