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The incidence of chronic kidney disease (CKD) in women of reproductive age is estimated to be between 0.1 and 4%. Pregnancies in women with CKD remain high risk and are associated with complications such as preterm delivery, intrauterine growth restriction, increased need for neonatal intensive care unit (NICU) admission, and hypertensive disorders including preeclampsia and eclampsia.
Over the past five decades, pregnancy outcomes in women with CKD have improved significantly, particularly in developed countries. Maternal mortality is now extremely low, and foetal survival has increased markedly, even among women with advanced CKD. Hladunewich et al. in Toronto reported 86% foetal survival rate in pregnant patients receiving haemodialysis.
In developing and lower-income countries, however, pregnancy in women with advanced CKD, particularly stage 5, remains highly challenging. In such cases, termination is often raised as a safer option. Nevertheless, if the patient chooses to continue, favourable outcomes may still be achieved with intensive multidisciplinary care and timely initiation of dialysis.
Herein, we report the case of a woman with CKD stage V who underwent protective haemodialysis with close monitoring, resulting in the successful delivery of a healthy infant.
Data were collected retrospectively from the hospital’s electronic medical records (EHIS).
A 40-year-old woman with a background medical history of hypertension, type 2 diabetes mellitus, morbid obesity (BMI 33) and CKD stage IV secondary to obstructive uropathy. She previously underwent left percutaneous nephrolithotomy for left staghorn calculi in Dec 2021 and right percutaneous nephrolithotomy for renal calculi in Jan 2022. Following these procedures, she was lost to follow-up.
She presented to primary care at nine weeks of gestation and was found to have a serum creatinine of 316 µmol/L with an estimated glomerular filtration rate of 15.8 mL/min/1.73 m². She was promptly referred to a tertiary hospital for further management. This was her fifth pregnancy, and she had four living children.
Ultrasonography revealed right hydronephrosis, which was confirmed by magnetic resonance urography showing moderate right hydronephrosis due to external compression from the gravid uterus. No renal or ureteric calculus was detected on the right side. On the left, a staghorn calculus was present with secondary renal atrophy; the bipolar length of the left kidney measured 6.3 cm with a cortical thickness of 0.5 cm.
After counselling by a multidisciplinary team including nephrologists, maternal–fetal medicine specialists, and a urologist, the patient elected to continue with the pregnancy. She was closely monitored and haemodialysis was initiated at 17 weeks of gestation via a right internal jugular vein catheter due to worsening renal function, with urea level of 18 umol/l with metabolic acidosis of 17mEq/l. Dialysis was scheduled three times per week. Weekly monitoring included full blood count, renal function tests, and venous blood gases. On average, her laboratory values showed a haemoglobin of 9.8 g/dL, urea of 11.2 mmol/L, and bicarbonate of 23.4 mmol/L.
Haemodialysis prescriptions were prescribed weekly by the nephrologist with extraction tailored to fluid status and expected weight gain. She was followed up with an obstetrician 4 weekly in the second trimester and 2 weekly in the third trimester. She remained stable and did not require hospitalization throughout the course of haemodialysis.
She was electively admitted and delivered at 31 weeks and 5 days of gestation by lower segment caesarean section. The baby was born without congenital anomalies, weighing 1.79 kg, and was admitted to the neonatal intensive care unit for respiratory distress syndrome. The infant was discharged after 25 days of hospitalization with a weight of 2.13 kg. The mother remained dialysis dependent and continued on regular haemodialysis.
In women with chronic kidney disease, successful pregnancy is attainable with timely haemodialysis and collaborative multidisciplinary care. This case highlights that careful planning and coordinated management can lead to a favourable outcome for both mother and child.
