Table 2. Recommendations in dialysis prescription during pregnancy.
| Dialysis intensification | |
|---|---|
| Hemodialysis | |
| ◦ | Increase in dialysis duration to 24 to 36 hours per week ¥ (5 to 7 sessions/week) |
| ◦ | Keep Predialytic urea levels < 30-50 mg/dL |
| ◦ | Dry weight increase in 300-500 mg weekly in the 2nd and 3rd trimesters |
| ◦ | Minimum needed heparinization. Cumarin anticoagulants are contraindicated |
| ◦ | Use of biocompatible membranes |
| ◦ | Avoid hypocalcemia. Recommended potassium levels in the dialysate between 3.0-3.5 mmol/L. Need for weekly electrolyte monitoring |
| Peritoneal dialysis | |
| ◦ | Increase the exchange frequency and reduce the volumes (usually <1.5L) |
| ◦ | Adding COPD and APD to optimize the technique |
| Blood pressure control | |
| ◦ | Target blood pressure after the dialysis session: 140-120/ 70-90 mmHg |
| ◦ | Objective volume monitoring, if possible (bio impedance option) |
| ◦ | Avoid hypotension and volume depression episodes |
| ◦ | ACEI, ARA II and minoxidil are contraindicated |
| Anemia | |
| ◦ | Increase in ESA dose to maintain the hemoglobin levels of 10-11 g/dL and the hematocrit between 30% and 35% (a 50-100% increase is usually necessary) |
| ◦ | Iron supplementation to maintain transferrin saturation above 30%. Oral supplementation is usually not enough, and intravenous administration may be necessary |
| Phosphorous-calcium metabolism | |
| ◦ | Avoid hypocalcemia and hyperphosphatemia. Weekly monitoring and calcium carbonate 1-2 g/D supplementation are recommended, if indicated |
| ◦ | Avoid hypercalcemia after the dialysis. If needed, adjust dialysate calcium (recommended dialysate calcium dosage of 1.50 mmol/L) |
| ◦ | 1,25-di-hidroxivitamin D (calcitriol) is recommended in cases of primary hyperparathyroidism or vitamin deficiency |
| Acid-base disorders | |
| ◦ | Avoid metabolic acidosis |
| ◦ | Lower doses of bicarbonate are recommended in the dialysate (25 mmol/L), because frequent hemodialysis may increase the risk of metabolic alkalosis |
| Nutrition | |
| ◦ | Supplementation with folic acid and Complex B vitamins |
| ◦ | Increase protein uptake to 1.8 g/kg/D of the pre-pregnancy weight + 10-20g/D |
| ◦ | Increase the caloric uptake to 35 Kcal/kg of the weight during pregnancy + 300 Kcal/D |
¥
The recommended dialysis time per week varies in the literature, and there was a benefit if higher than 20h and higher than 36h. Less than 20h/week was associated with worse outcomes.3
COPD – Continuous Outpatient Peritoneal Dialysis
APD – Automatic Peritoneal Dialysis
ACEI – Angiotensin Converting Enzyme Inhibitors
ARA II – Angiotensin II Receptors Antagonists
ESA – Erythropoiesis Stimulating Agent