Pregnancy in patients with chronic kidney disease and on dialysis
Chronic kidney disease (CKD) affects a small but increasing minority of women becoming pregnant. It is associated with additional risks depending on pre-pregnancy glomerular filtration rate, proteinuria, and hypertension. Some drugs are contraindicated in pregnancy. These are powerful reasons for counselling all women of childbearing age about pregnancy in CKD. With minor CKD the main issue is moderately increased risk of pregnancy-associated hypertension and pre-eclampsia. More advanced CKD is associated with reduced fertility, progressively increased risk of pre-term delivery and a significant chance of permanent loss of maternal renal function. Distinguishing pre-eclampsia from the natural effects of pregnancy on manifestations of CKD can be challenging. Blood pressure targets may be modified during pregnancy and angiotensin converting enzyme inhibitors and angiotensin receptor blockers are contraindicated. Dialysis may be initiated if pregnancy occurs at advanced levels of CKD. Pregnancy may also occur in patients on dialysis, usually in women with some residual native renal function. More intensive dialysis may improve outcomes.