Table 3.

Recommended medical management for pregnant women with kidney failure

Dialysis recipient	Transplant recipient
Model of care
•Establish a team including nephrologists, obstetricians with maternal-fetal medicine and high-risk pregnancy experience, midwives, and allied health support, including dietetics, psychology, and pharmacy. Identify the coordinator of care. •Care close to a tertiary center for expert nephrology, transplant, and obstetrical care.
Medications
•Stop phosphate binders, calcimimetics •Switch to pregnancy-safe antihypertensives •Commence low-dose aspirin 75–150 mg daily	•Switch to pregnancy-safe antihypertensives and immunosuppression •Cease antiviral therapy •Commence low-dose aspirin 75–150 mg daily
Modality-specific management
•Measure residual function •Consider PD switch to HD where feasible •Titrate dialysis hours and frequency based on residual function; aim for predialysis urea < 12 mmol/l •Implement intensive dialysis regimen (>36 h/wk, titrated to predialysis urea) in women with no residual function •Do not use Kt/V to assess clearances •Use minimal anticoagulation •Regularly review and titrate dialysate composition based on bicarbonate, potassium, calcium, and phosphate blood levels •Adjust peritoneal dialysis prescription to increase clearances; reduce volume if required for patient comfort •Frequently review and adjust dry weight by 0.3–0.5 kg/wk from second trimester •Monitor dialysis access closely for infection and complications •Minimum weekly clinical review	•Minimum monthly clinical review and measurement of renal function, proteinuria, and immunosuppressive trough levels •Increase frequency of review as gestation progresses. •Anticipate a fall in whole blood (bound) trough CNI levels in the second trimester. Interpret falling CNI levels cautiously and beware of potential toxicity after dose increases •Consider transplant biopsy if acute graft dysfunction without clinical suspicion of pre-eclampsia; balance value of biopsy against gestational age and likelihood of early delivery
Blood pressure
•Recommend home BP monitor •Vigilance for superimposed pre-eclampsia •Consider sFLT1/PlGF levels where available •Aim for BP <135/85 mm Hg •Avoid placental hypoperfusion from intradialytic hypotension	•Recommend home BP monitor •Vigilance for superimposed pre-eclampsia •Value of sFLT1/PlGF levels uncertain •Aim for BP <135/85 mm Hg •Avoid hypotension <110/70 mm Hg
Anemia
•Use ESA to achieve target Hb 110 g/dl •Ensure iron stored are replete according to local protocols •Develop criteria for blood transfusion—optimize hemoglobin to avoid transfusion
Infection
•Monitor closely for catheter sepsis or AVF infection •Screen for and treat bacteriuria/UTI; consider prophylaxis •Coronavirus vaccination	•Screen for and treat bacteriuria/UTI; consider prophylaxis •Coronavirus vaccination •Screen/monitor for CMV in women at risk (past CMV, previous prophylaxis)
Nutrition
•Start or increase dose of vitamins C, B and folic acid supplements •Reduce fluid, potassium and phosphate restrictions; may require supplementation •Expert dietitian involvement to optimize protein and calorie intake	•Dietitian review as required
Diabetes screening
•Early screening (16–20 wks) in high-risk patients (prednisolone, tacrolimus, family history, past gestational diabetes mellitus, obesity) •Routine screening at 28 weeks’ gestation or as per local practice
Diabetes management
•Diabetes education and dietitian •Insulin therapy	•Diabetes education and dietitian •Metformin or insulin
Fetal monitoring
•Dating, morphology scans, and first trimester screening as per local practice •Consider noninvasive prenatal testing (cell-free DNA) for aneuploidy •Frequent (fortnightly) growth scans in third trimester to monitor growth restriction, amniotic fluid index, and vascular changes suggesting pre-eclampsia
Delivery and early postpartum care
•Stop aspirin at 35 wks gestation •Develop and regularly review the “goal posts” for delivery including timing •Trial of labor is not contraindicated •Clarify transplant anatomy before delivery •Steroid “stress dose” if on chronic glucocorticoid therapy •Avoid nonsteroidal anti-inflammatory medications for pain relief •Consider venous thromboembolism prophylaxis following operative delivery •Urgent post-delivery transplant imaging for any reduction in function or urine output •Establish breastfeeding if desired by mother; support decisions about breastfeeding
Postpregnancy care
•Contraception in place •Psychosocial support •Resume nonpregnant dialysis prescription •Monitor residual renal function	•Contraception in place •Psychosocial support •Close monitoring of graft function and CNI levels •Adjust/reinstate medications

AVF, arteriovenous fistula; BP, blood pressure; CMV, cytomegalovirus; CNI, calcineurin inhibitor; ESA, erythropoiesis-stimulating agent; Hb, hemoglobin; HD, hemodialysis; sFLT1, soluble fms-like tyrosine kinase 1; PD, peritoneal dialysis; PlGF, placental growth factor; UTI, urinary tract infection.