Nutritional Implications of Pregnancy in Dialysis: A Case Study

Lesley L. McPhatter
Joanne C. Drumheller

Pregnancy is associated with a permanent decrease in glomerular filtration rate (GFR) of 0-10% in women with normal to mildly reduced GFR (plasma creatinine less than 1.5 mg/dL) at pregnancy onset. Renal function declines as a result of pregnancy depending on the severity and the underlying disease. Major risk factors for chronic deterioration of kidney function are elevated plasma creatinine (Cr) levels (above 1.5 mg/dL) and hypertension. The risk for irreversible decline exceeds 50% in women with uncontrolled blood pressure (August, Vella, & Sayegh, 2007).

In June 2007, at 18 weeks gestation, a 29-year-old Vietnamese female was diagnosed with IGA nephropathy after renal biopsy. The patient was followed by a nephrologist and a high-risk obstetrician/gynecologist (OB/GYN) for conservative management of her chronic kidney disease (CKD) and pregnancy. She was started on Erythopoeitin and treated with Kayexalate® for increasing serum potassium levels. In July, she was seen in the nephrology clinic at 25 weeks gestation with creatinine up to 5.6 mg/dL and increasing hypertension, hyperkalemia, and anemia. She had a subclavian catheter placed and started on hemodialysis July 27, 2007 in the inpatient hospital unit. The hemodialysis prescription was for 5 consecutive days for 3 hours at a blood flow rate (BFR) of 350 mL/min and dialysate flow rate (DFR) of 800 mL/min. The dialysate contained potassium (K+) 3 mEq/L and calcium (Ca++) 2.5 mg/dL. She was subsequently discharged home on August 3 and began outpatient dialysis in our center August 6.

The patient was seen on August 7 for initial nutrition assessment and physician evaluation. The patient had only tolerated about 2 hours of the acute care hospital dialysis treatment regime as treatments were terminated early each time due to nausea, vomiting, and low blood pressure. The patient’s dialysis prescription was adjusted to 5 days/week, Monday-Friday for 4 hours, for a total of 20 hours of treatment per week. The patient was agreeable to increased dialysis time but was not willing to come for treatment on the weekends at this point. With the BFR reduced to 300 mL/min, a DFR of 400 mL/min, and a dialysate of K+ 2.0 mEq/L, Ca++ 2.5 mg/dL, the patient was able to tolerate 4-hour treatments at each visit.

The patient’s measured height was 152 cm (60 inches) and initial weight was 50 kg (110 lb). Lab parameters revealed an albumin of 2.4 g/dL, total protein 4.3 g/dL, K+ 4.2 mEq/L, BUN 39 mg/dL, Cr 4.4 mg/dL, Ca++ 7.3 mg/dL (adjusted for albumin 8.5 mg/dL), phosphorus 3.4 mg/dL, intact PTH 197 pg/mL, hemoglobin 8.3 g/dL, transferrin saturation 37%, and cholesterol 325 (HDL 76, LDL 186). Patient medications included prednisone 40 mg started to possibly improve urine output prior to dialysis, and this was continued. Her blood pressure was treated with Labetalol® 200 mg daily. The patient was started on Erythropoetin® (EPO) 5,000 units three times/week and intravenous (IV) iron sucrose (Venofer®) 50 mg each week. Her cholesterol level was not treated with medications due to pregnancy. The patient had been on prenatal vitamins, and these were continued to minimize medication change, though the preferred vitamin for pregnant dialysis patients is a renal vitamin with at least 2 mg folic acid (Stover, 2004).

Dietary recall indicated a diet low in protein with an extremely poor appetite. The patient stated she had been instructed to limit potassium, fluid, and sodium intake. The traditional Vietnamese diet consists mostly of rice, beans, and vegetables with little or no dairy products (Tu, 2001). Protein needs for patients on hemodialysis with pregnancy are 1.2 g/kg ideal body weight (IBW) plus 10 gm. Kilocalorie (kcal) needs are 35 kcal/kg IBW plus 300 kcal in 2nd and 3rd trimester) (Stover, 2004). The patient was instructed on a 70 gm protein 2,000 kcal diet divided between small meals and snacks. The diet was liberalized without limits on phosphorus or potassium intake due to daily dialysis and to maximize nutritional intake. She tolerated milk and agreed to try to drink one glass per day while increasing fish, meat, egg, rice, nut, and bean intake to improve protein status. The patient was not willing to try protein/calorie nutritional supplements (Ensure®) or protein supplements (Proteinex®) initially. She agreed to try dried milk powder and egg white powder mixed with milk, but neither was well tolerated as the patient found the odor of the added powders to be offensive. Protein bars (Zone Perfect®) were also not well liked due to patient personal preference. The patient had a relatively small list of preferred foods from which she and her family worked to improve intake.

The patient’s laboratory data and target weights from onset of dialysis in the outpatient setting to delivery are shown in Table 1. The patient was seen daily by the dietitian for evaluation of intake and encouragement to continue to improve dietary intake. Appetite gradually improved and, though weight gains were minimal, protein status improved. The family was instrumental in improving her nutritional status by providing three cooked meals per day. The patient’s sister introduced her to Boost®, a protein/calorie nutritional supplement, and she willingly took 120 – 240 ml per day. Her husband found a Subway® sandwich she liked and would eat every treatment during dialysis. Serum phosphorus levels increased as protein intake improved and calcium acetate 667 mg/meal was added to bind phosphorus. Due to daily dialysis, potassium in the dialysate was increased to 3 mEq/L after just four treatments and serum potassium levels were stable in the normal range. Hemoglobin improved slowly with EPO dose adjustments up to 10,000 units thrice weekly and continued maintenance (50 mg/week) IV iron sucrose.

 

An ultrasound the week of September 10 when the patient was at 32 weeks gestation indicated only a 270 gm (9 oz) growth in the baby in the previous three weeks. Due to concerns about excessive uremic toxins on the 2-day weekend stretch, the dialysis schedule was changed to Monday – Tuesday and Thursday – Friday – Saturday, and remained at 20 hours/week. The patient did not appear to be responding to the prednisone and the dose decreased per a tapering schedule. The patient continued to have retarded intrauterine fetal growth and a caesarian section delivery (due to previous C-section with first child) was scheduled at 37 weeks gestation on October 17, 2007. The patient gave birth to a 1470 gm (3 lb, 2 oz) baby boy with Apgar score 8 and then 9. The baby was admitted to the neonatal unit and remained there until coming home on November 9, 2007 at 2010 gm (4 lb, 3 oz), the patient’s 30th birthday.

The patient was extremely overwhelmed, depressed, and emotional at the onset of dialysis. Significant time was spent with the individual interdisciplinary team members (nurse, patient care technicians, social worker, dietitian, and physician) to educate the patient on important issues related to the onset of CKD Stage 5 and the impact on her family, her business that she owned, nutrition and medication, and the risks of pregnancy during dialysis. Reducing her fears and concerns was critical to improving adherence with the treatment regime, nutritional intake requirements, and medication intake. The patient had a large and supportive family who were also instrumental in her success. Frequent gentle dialysis and adequate nutrition combined with a strong support network of family and care providers are critical for successful outcomes in this patient population.

References
August, P., Vella, J., & Sayegh, M. (2007). Pregnancy in women with underlying renal disease. Retrieved February 5, 2008, from http://patients.uptodate.com/topic.asp?file=renldis/5345

Stover, J. (2004). Pregnancy and dialysis. In L. Bynam-Gray & K.Wiesen (Eds.), A clinical guide to nutrition care in kidney disease, (pp. 121-126). Chicago: American Dietetic Association.

Tu, J. (2001). Nutrition and fasting in Vietnamese culture. Retrieved February 5, 2008, from http://ethnomed.org/cultures/ vietnamese/viet_food.htm