NDT Advance Access originally published online on September 11, 2007
Nephrology Dialysis Transplantation 2007 22(12):3671; doi:10.1093/ndt/gfm280
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Successful pregnancy in a patient with end-stage renal failure secondary to HIV nephropathy on peritoneal dialysis
Email: elhamasgari{at}yahoo.com
Sir,
Pregnancy in dialysis-dependent women is uncommon, with rates of conception being reported as 1–7%; the incidence of pregnancy on peritoneal dialysis (PD) is reported to be two to three times lower than that of haemodialysis [1]. In the 1980s, infant survival rates were as low as 23%. More recent reports suggest that up to 42% of babies survive in women who conceive after starting dialysis and up to 73.6% in women who started dialysis after conception [2].
HIV associated nephropathy (HIVAN) is usually a progressive disease, resulting in dialysis dependency [3]. There is evidence that highly active antiretroviral therapy (HAART) has beneficial effects on the prevalence and progression of HIVAN [4].
We report the case of a patient with dialysis-dependent renal failure due to HIVAN, on HAART, who became pregnant while on PD and had a successful delivery. To our surprise, she became independent of dialysis for 7 months following childbirth. The patient was a 26 year-old Zimbabwean, who presented with cervical and axillary lymphadenopathy and had renal impairment with Cr 169 µmol. Her HIV test was positive and she had a CD4 count of 32 cells/mm3 and viral load of 14 580 copies/ml. She underwent a renal biopsy which showed evidence of HIVAN and despite being started on HAART, she progressed to end-stage renal failure and opted for PD.
Ten months later, she was found to be pregnant, with an ultrasound of her pelvis showing a fetus at 23 weeks gestation. Her dialysis regime was increased and urea levels were maintained between 7.1–13.8 mmol/l. Her epoetin beta dose was increased to control anaemia and antiretroviral medications were adjusted. Her blood pressure remained within normal limits for gestation. She was switched to automated PD at 31 weeks of gestation, in order to reduce dwell volumes but maintain dialysis adequacy. An elective caesarean section was performed at 36 weeks gestation and she delivered a healthy baby boy. PD was discontinued just prior to caesarean section, with a view to transferring her to haemodialysis, but surprisingly, she remained independent of dialysis. She unfortunately stopped taking her HAART and became dialysis-dependent again 7 months post partum.
Pregnancies in women with HIV are now increasingly common, due to the success of HAART in dramatically reducing the morbidity and mortality of the disease. Its routine use in pregnancy is now recommended regardless of viral load.
This case demonstrates that, for patients with HIVAN and end-stage renal failure treated with PD, a viable pregnancy is possible with the use of HAART and without the need to switch from PD to haemodialysis. Increased dialysis dose can be achieved with automated PD, which allows for frequent exchanges and smaller dwell volumes.
Acknowledgement
We would like to acknowledge the assistance of Dr George Attallah and Dr Steven Estreich in GU medicine, as well as that of the CAPD nursing staff.
Conflict of interest statement. None declared.
Notes
See http://www.oxfordjournals.org/our_journals/ndtplus/
References
- Holley JL, Reddy SS. Pregnancy in dialysis patients: a review of outcomes complications and management. Semin Dial (2002) 16:284–287.
- Okundaye I, Abrinko P, Hou S. Registry of pregnancy in dialysis patients. Am J Kidney Dis (1998) 31:766–773.[Web of Science][Medline]
- Szczech LA, Edwards LJ, Sanders LL, et al. Protease inhibitors are associated with a slowed progression of HIV-related renal diseases. Clin Nephrol (2002) 57:336.[Web of Science][Medline]
- Atta MG, Gallant JE, Hafizur Rahman M, et al. Antiretroviral therapy in the treatment in HIV-associated nephropathy. Nephrol Dial Transpl (2006) [July 24 Epub].
- Watts DH. Management of human immunodeficiency virus infection in pregnancy. N Engl J Med (2002) 346:1879–1891.
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