A STUDY ON OUTCOMES OF ACUTE INTERMITTENT RIGID CATHETER PERITONEAL DIALYSIS IN POST PARTUM PREGNANCY RELATED ACUTE KIDNEY INJURY PATIENTS

Peritoneal dialysis in pregnancy, while possible, is challenging and associated with increased risks for both mother and fetus. Acute kidney injury during pregnancy, especially when requiring dialysis is a serious complication with high maternal and fetal morbidity and mortality. Early intervention and careful management are therefore crucial. Transplantation provides best pregnancy outcomes for patients with kidney disease during pregnancy, dialysis during pregnancy is now a viable option for those who anticipate difficulty receiving a renal transplantation. The first successful full term pregnancy in an end stage renal disease, where patient was on hemodialysis was 1st reported in 1971 by confortini et al. Some 12 years later the 1st sustained pregnancy where mother received peritoneal dialysis was reported in a patient who had been receiving treatment for 2.5 years. The pregnancy was sustained till 30 weeks and a still born infant was delivered, after a spontaneous labour.In women with renal insufficiency , the presence of both GFR less than 40 ml/min / 1.73m 2  and proteinuria with protein greater than 1gm/day before conception predicts poor maternal and fetal outcome

Despite many challenges faced by pregnant ESRD women , the rate of successful pregnancy increased from  50% in 1990s to 80% in recent years, once the patient was successfully conceived. From 54 reported cases of pregnant women receiving PD available in literature since 1983, 47% cases have resulted in successful pregnancy but only 6 cases were full term deliveries. The improved pregnancy outcomes were interlinked with adequate residual urine, conception during peri-initiation of PD, medication adjustment , tailoring PD prescription, blood pressure control. Patients on peritoneal dialysis were less likely to achieve a pregnancy compared with hemodialysis patients (P<0.02).

Our study focussed on acute intermittent rigid catheter peritoneal dialysis in postpartum pregnancy related AKI and assessing its outcomes. Pregnancy related AKI is a major public health problem , endangering the lives of mothers and their babies , particularly those living in developing countries. Potential disparities between high , low and lower middle income countries exist because of insufficient health care resources, nephrology workforce and infrastructure. Acute kidney injury seriously affects the health of both pregnant women and fetuses.

However our study focussed on rigid catheter peritoneal dialysis in postpartum patients with AKI.

This was a single center observation study conducted from May 2020 to may 2025 (5 years) at Gandhi Hospital, Hyderabad, a tertiary care, public sector teaching hospital. 42 patients with PrAKI treated with PD as the initial mode of RRT were included in the study.. All patients were followed up until discharge and their BP and eGFR was recorded. The study population included the pregnancy cases referred from the OBG department in view of acute kidney injury. All postpartum AKI cases were included, gravid and CKD -5d cases were excluded.  The primary outcome of the study was to measure maternal and fetal outcomes. Secondary outcomes were to assess parameters between survivors and non survivors.  Complete recovery was defined as return of the serum creatinine to baseline or normal range at the time of discharge. Partial recovery was defined as the decrease in serum creatinine, not to baseline but independent of RRT requirements

Statistical analysis was performed using a statistical package for social sciences.  Data was entered into Microsoft excel data sheet and was analysed using SPSS 22 version software and Epi-info version 7.2.1 (CDC Atlanta) software. Categorical data was represented in the form of Frequencies and proportions. Chi-square test was used as a test of significance for qualitative data. Continuous data was represented as mean and standard deviation. Multivariate logistic regression was used to compare characteristics between survivors and non survivors.

The incidence of PrAKI among all AKI admissions in our institute is 0.76%. 583 PrAKI patients were admitted during the study period. 7.2% patients were given peritoneal dialysis. 38.4% patients were managed conservatively. 54.3% of patients underwent HD. All patients who underwent PD were postpartum

In the present study, the majority of subjects (69.0%) were below 25 years of age, while 31.0% were above 25 years. With respect to parity, 52.4% were primigravida and 47.6% were multigravida. Most subjects were in the post-partum period (66.7%), whereas 33.3% were in the third trimester. Notably, 52.4% of subjects had preeclampsia, while 47.6% did not. The majority of deliveries were by lower segment cesarean section (LSCS) at 92.9%, with only 7.1% delivering vaginally. Intrauterine death (IUD) was reported in 35.7% of cases, with 64.3% showing no IUD. Among the reasons for referral, 52.4% were due to combined renal dysfunction and oliguria, 26.2% for renal dysfunction alone, 11.9% for oliguria, and 9.5% for anuria.

In this study, PD was initiated within 3 days for half of the subjects (50.0%). For 42.9% of the subjects, PD was started at 3 to 7 days, while only 7.1% had PD initiation beyond 7 days. 

Renal dysfunction was the most common indication for initiating PD, observed in 40.5% of the cases. Oliguria accounted for 33.3%, followed by fluid overload in 16.7% and anuria in 9.5% of the subjects. This suggests that the majority of cases had renal impairment or fluid imbalance as the primary indication. 

Full recovery ( serum creatinine less than 1 mg/dl) was documented in 28.5% of the subjects, partial recovery ( deranged RFT but not requiring dialysis) was observed in 57.1%  subjects while 14.2% were  progressed to CKD -5D. 

61.9% of the babies were alive, while intrauterine death (IUD) occurred in 35.7% of cases. Neonatal death was noted in 2.4% of the cases. 

26.2% of the subjects did not experience any complications related to peritoneal dialysis (PD). However, PD leak was the most common complication, observed in 23.8% of the subjects. Exit site infection was reported in 14.3%, followed by bleeding in 11.9%, PD block in 9.5%, and peritonitis in 4.8% of cases. Less common complications included infection, high blood sugars, catheter block, and sepsis—each accounting for 2.4%.

In this study, comparison of biochemical parameters revealed that SGOT and SGPT levels were significantly higher in non-survivors (117.89 ± 13.6 IU/L and 126.46 ± 11.7 IU/L, respectively) compared to survivors (42.84 ± 7.8 IU/L and 47.43 ± 7.4 IU/L, respectively), with p-values of 0.02 and 0.021, indicating a statistically significant difference. Serum creatinine before PD was also significantly higher among non survivors (4.32 ± 2.13 mg/dL) than in survivors (2.75 ± 1.29 mg/dL), with a p-value of 0.005. Day of initiation of peritoneal dialysis postpartum is low  in survivors compared to non survivors, signifies that early initiation improved outcomes of survival with a significant p. value of 0.036*.  Other parameters such as Hb, WBC, platelet count, ALP, TSB, blood urea, did not show statistically significant differences between the groups (p > 0.05), although notable trends were observed.

Demographic and clinical variables showed no statistically significant association between survival outcomes and age, parity, gestational period, presence of hypertension, preeclampsia, mode of delivery, or referral source (p > 0.05 for all). Though all three vaginal deliveries resulted in non-survival, and all hypertensive subjects died, these differences did not reach statistical significance, possibly due to small subgroup sizes.

Analysis of outcome-related factors revealed no statistically significant association between child condition and maternal survival (p = 0.575), though 71.4% of survivors had live births compared to 57.1% of non-survivors. The type of dialysis showed a trend toward significance (p = 0.05), with PD alone being more common among non-survivors (89.3%) than survivors (64.3%), while PD+HD was more frequently used in survivors (35.7%) than non-survivors (7.1%), signifying combination of PD+ HD improved survival outcomes. 

PrAKI is associated with higher mortality and poorer outcomes. Among non survivors, higher SGOT and SGPT levels , serum creatinine before PD along with delayed  initiation of PD were statistically significant in causing mortality . 

Survival outcomes are better when PD is done along with HD compared to PD alone.