First successful pregnancy on peritoneal dialysis in Reunion island

Abstract

We report the first successful pregnancy on peritoneal dialysis (PD), in 2023, in the overseas territories and departments (DOM-TOM) of France, in LA REUNION island, in a 34-year-old woman, a nurse by profession. She had been treated with continuous ambulatory peritoneal dialysis (CAPD) since February 2022. The original nephropathy was Alport syndrome.

Pregnancy began twenty months after the start of dialysis. The patient wished to continue her pregnancy in CAPD in order to carry out exchanges during the day in her office, so as to be more available to her family in the evening.

The first trimester of pregnancy was uneventful. During this period, the patient was informed of the risks of pregnancy, and together we defined our objectives with the means available. Adjuvant drug prescriptions (calcium, aspirin, iron, folic acid, vitamin D, etc.) were adapted during the second trimester, as was the PD protocol, in line with defined objectives. The third trimester required largely hospital-based management.

Infusion volumes were progressively reduced, while the frequency of infusions was increased, thereby increasing the total daily volume of dialysis.  Residual renal function remained stable throughout the pregnancy, and plasma urea levels were kept below 20 mmol/L.

She was delivered by Caesarean section under spinal anaesthesia at 33 weeks and 4 days of amenorrhea, with the birth of a 1,800g boy with Apgar coefficients of 5 at 1min, 8 at 3min and 9 at 5min. The baby's development and growth were very satisfactory.

Respect for the patient's choices, her autonomy and her participation in the treatment were decisive factors in the success of the procedure.

CASE PRESENTATION

History

The patient, a 34-year-old nurse, was diagnosed with stage 2 renal failure secondary to Alport syndrome (COL4A3) in 2012. She reported no allergies or intolerances and denied any history of smoking or alcohol consumption. Her viral serologies for hepatitis B, C, and HIV were unremarkable.

In 2016, she experienced her first pregnancy, which resulted in a cesarean section delivery at 30 weeks gestational age (GA). During this period, there was a notable decline in her renal function, characterized by the onset of nephrotic syndrome and acute renal failure, with creatinine levels peaking at 650 µmol/L; HD was not initiated. A subsequent renal biopsy illustrated pauci-immune vasculitis accompanied by extracapillary proliferation. Postpartum management included plasma exchange and the administration of the monoclonal antibody rituximab.

The patient’s surgical history is significant for a right breast lumpectomy and radiotherapy in 2017. However, in 2020, she experienced an aggressive tumor recurrence, necessitating chemotherapy, a right breast mastectomy, and targeted trastuzumab therapy. Nephropathy continued to progress after delivery, reaching stage 5 in 2021. Consequently, she commenced PD therapy in February 2022.

Pregnancy follow-up

A subsequent pregnancy was identified in the patient while she was undergoing PD, estimated to have started on October 11, 2022. Prior to the pregnancy, her diuresis was maintained at approximately 1500 mL daily, and she weighed 62 kg with a height of 170 cm. The ultrafiltration facilitated by PD ranged between 500 and 700 mL daily.

Her CAPD treatment regimen included two bags of isotonic glucose solution (GI) (PHYSIONEAL®) and one bag of amino acids (AA) (NUTRINEAL®) during the daytime, coupled with one bag of glucose polymer (ICODEXTRIN®) for extended stasis in the evening. The exchange volume was set at 1.6 L to ensure abdominal comfort. While intraperitoneal pressure was not measured, PD efficiency calculations using the Registre de Dialyse Péritonéale de Langue Française software indicated satisfactory outcomes: the total weekly peritoneal creatinine clearance stood at 27 L, urea Kt/V was at 3.6, and the residual renal clearance oscillated between 4 and 5 mL/min, with the most recent four measurements being 4.93, 4.79, 4.49, and 3.97 mL/min, respectively.

During the first trimester, we augmented our guidance by elucidating the potential pregnancy risks to the patient, encompassing arterial hypertension, eclampsia, preeclampsia, intrauterine growth retardation, prematurity, hypotrophy at birth, and intrauterine demise. This vital information was documented in the medical record. Issues specific to PD were also addressed, with a focus on concerns such as the risk of peritonitis, preterm delivery, and challenges posed by the gravid uterus in maintaining exchange volume. The patient was informed about the potential of elevated maternal urea levels to induce osmotic diuresis in the fetus once its kidneys become functional, possibly leading to hydramnios. Additionally, the importance of understanding the potential for hemodynamic instability and blood pressure variances was highlighted, especially given their ability to adversely impact placental blood flow in the context of conventional HD.

Regarding medication, the administration of drugs considered to be incompatible with pregnancy was ceased. Specifically, the oral calcimimetic (MIMPARA®) was stopped, and the AA bag was substituted with a GI bag (PHYSIONEAL®).

The patient was informed of the significance of continuing with PD, especially considering the clinical recurrence of vasculitis from a prior pregnancy. This entails potential symptoms such as asthenia, general deterioration, and inflammatory syndrome, among others. The importance of preventing the onset of nephrotic syndrome—with potential complications like severe edema, significant arterial hypertension, and challenging hydro-sodium overload in PD—was emphasized. Additionally, concerns regarding the potential pregnancy outcome while on PD were addressed.

Beyond standard PD monitoring, checks were made for serum folate, vitamin D, and magnesium levels. Deficiencies in these elements could lead to uterine contractions. Screening for anti-SSA and SSB antibodies took place due to their identification as risk factors for atrioventricular block. The patient received advice to undertake a weekly urine dipstick test, with the option to use PD dipsticks. In the event of positive results, a urine cytobacteriological study was suggested, along with a monthly 24-hour proteinuria test.

For the second trimester, nephrological consultations increased to bimonthly intervals. Outpatient prescriptions included folic acid supplementation and native vitamin D, even though existing levels were within the acceptable range (vitamin D at 88 nmol/L, folic acid at 7 µg/L). This adjustment accounted for increased requirements during pregnancy. Magnesium was not prescribed due to concerns surrounding its use in chronic kidney disease patients and the current dosage being deemed sufficient at 0.79 mmol/L. An episode of cystitis due to methicillin-resistant Staphylococcus epidermidis was treated with a 7-day course of pristinamycin. Subsequent urine cytobacteriological evaluations returned negative results 10 days post-treatment.

Within the framework of obstetric-gynecologic monitoring, two ultrasounds were performed: one at 13 weeks GA for prenatal diagnosis and another at 16 weeks for early morphological assessment. Both results were reassuring. In an effort to prevent potential complications, acetylsalicylic acid 100 mg was prescribed for noon intake.

The third trimester presented the most challenges, resulting in hospitalization. At 27 weeks GA, clinical indicators were positive: blood pressure was stable, and weight was satisfactory at 69 kg (a gain of +7 kg). Yet, severe hypoalbuminemia at approximately 20 g/L prompted the prescription of low-molecular-weight heparin (CALCIPARINE®) to prevent thrombosis. At 28 GA, the patient experienced an isolated, painless hemoperitoneum, which subsided fully within 2 days after several peritoneal lavages. An ultrasound revealed hydramnios while maintaining a well-closed cervix. It was advised that the patient rest and receive

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