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Introduction: Chronic kidney disease (CKD) is described in around 4% of women of reproductive age, leading to low pregnancy rates due to common amenorrhea and anovulation in these patients. Pregnancy requires metabolic, physiological, and hemodynamic adaptations to support correct fetal development, but these adaptations have lower capacity in women with CKD. There is limited experience with nutritional interventions, including the use of keto-analogues (KAs) in pregnant women before dialysis, necessitating further study.
Clinical case: This case involves a 26-year-old female diagnosed with stage IV CKD of unknown cause, with 3 years of evolution. Renal Doppler ultrasound revealed echogenic kidneys, with the left kidney smaller and displaying mild cortical thinning, indicating bilateral chronic nephropathy. Additionally, there was a likely double right pyelocaliceal system with upper system atrophy and mild calyceal dilation. Blood pressure was measured at 135/78 mmHg. Nutritional therapy included a diet 30 kcal/kg ideal weight, a very low-protein diet (0.4 g/kg ideal weight), KAs (1 tablet/5 kg ideal weight), low phosphorus and sodium intake, and unrestricted water consumption. Six months into the treatment, an 8-week pregnancy with a single embryo was detected. The decision was made to continue treatment during pregnancy, with adjusted KAs dosage (1 tablet/10 kg ideal weight) and added high biological value protein and dairy servings to compensate for KAs reduction. Lipid and carbohydrate intake remained unchanged, and total caloric intake was increased by 100 kcal based on the caloric module and olive oil. The patient experienced dilutional hyponatremia, which was closely monitored. Total fluid intake was restricted to 1500 cc, and 1 gram of salt was added. At 20 weeks of gestation, the pregnancy continued with appropriate maternal and fetal weight gain, good dietary adherence, and KAs supplementation. Caloric intake was further increased to 35 kcal/kg ideal weight, supplemented with 200 kcal. Protein intake remained at 0.6 g/kg, and KAs were administered at 1 tablet/10 kg of ideal weight (6 tablets/day). At 33 weeks of gestation, the pregnancy progressed normally for both mother and fetus. At 34+4 weeks, the patient was hospitalized for a cesarean section, resulting in the birth of a healthy male newborn weighing 2.5 kg and measuring 44 cm. The baby actively breastfed exclusively for one month.
Discussion: This case demonstrates the possibility of a successful pregnancy with standard clinical and nutritional progress, achieving adequate maternal and fetal weight gain. The patient faced a mild nutritional risk index, which returned to baseline levels after the pregnancy ended. Timely nutritional management, including strict monitoring of protein intake supplemented with keto-analogues, may be a therapeutic option to optimize the maternal-fetal prognosis in advanced-stage CKD.