Walker W1, Xiao Y1, Pham T1, Jesudason S2, Craven A3, Ranganathan D4
1Department of Nephrology, Royal Brisbane and Women’s Hospital, Herston, Australia, 2Department of Nephrology, Royal Adelaide Hospital, Adelaide, Australia, 3Department of Obstetric Medicine, Royal Brisbane and Women’s Hospital, Herston, Australia, 4School of Medicine, Griffith Universtiy, Southport, Australia
Background: Chronic Kidney Disease Stage 5 on haemodialysis (CKD G5D) is associated with significant infertility and it disproportionately affects the Aboriginal population. While the Australian and New Zealand Dialysis and Transplant Registry has recorded 7 live births for Aboriginal or Torres Strait Islander women on haemodialysis (HD), no reports documented the intrapartum management of this cohort.
Case Report: A 34-year-old, Aboriginal woman (weight 45 kg) with CKD G5D secondary to diabetic nephropathy presented at 9 weeks of gestation. She had a background of type 1 diabetes mellitus, asthma and hypertension and was engaged in multidisciplinary healthcare. Given she had no residual renal function, we increased her HD time from 12 hours/week to 26 hours/week (4 hours on weekdays and 6 hours on Saturdays), aiming for a pre-HD urea ≤ 12.5mmol/L. Her pre-dialysis urea dropped from 22 to 7.8mmol/L within 6 weeks. She was further fluid restricted to 1 litre to manage her interdialytic weight gain. At 27 weeks and 3 days, an emergent lower segment caesarean section was performed for foetal distress secondary to placental insufficiency. A live female baby with intrauterine growth restriction (birth weight 701g) was delivered.
Conclusions: This is the first case in Queensland of an Aboriginal woman with CKD G5D delivering a live baby. We propose that using pre-dialysis urea to titrate dialysis duration is a reasonable approach in these challenging patients. Some might postulate gestational age could be lengthened with prolonged dialysis hours >36 hours/week consistent with Canadian centre recommendations. Unfortunately, the practicality of this is often challenging due to compliance and resource availability. More research is needed, particularly in the Aboriginal population who are significantly affected by CKD.
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