Improving Care for Patients with Kidney Disease Who Are Pregnant, Undergoing Dialysis

In an interview with Pharmacy Times, Silvi Shah, MD, MS, FASN, assistant professor in the Division of Nephrology and Hypertension at the University of Cincinnati, Ohio, discusses the strategies and care goals for patients with kidney disease who are pregnant and undergoing dialysis, who are at high risk for both adverse maternal and fetal outcomes. Shah will be presenting at the panel “Epidemiology and Outcomes of Pregnancy in Patients on Dialysis” during ASN Kidney Week in Philadelphia, Pennsylvania (November 2, 2023, to November 5, 2023).

Pharmacy Times: Could you discuss the strategies and approaches for dialysis in pregnant patients, and what are the primary goals of care in this population?

Silvi Shah: So, pregnancy in patients with kidney failure undergoing dialysis is very high-risk and is associated with adverse maternal and fetal outcomes. One of the things which has shown to improve fetal outcomes includes intensive hemodialysis. So, currently any patient who has kidney failure is undergoing dialysis 3 times a week for 4 hours during each session. And what studies have shown and what data has shown us is that intensive hemodialysis improves fetal outcomes, so it increases the chances of live births, it reduces the risk of preterm births, and it reduces the risk of low-birthweight babies. So, the strategy is to intensify hemodialysis and ideally, we should try to intensify as much as we can, so maybe try for 6 days a week for around 6 hours each session. So that is what our goal is: to intensify hemodialysis to improve fetal outcomes.

Pharmacy Times: How are pregnant individuals with kidney disease who are on dialysis able to manage hypertension, and what risks are associated with hypertension during pregnancy?

Shah: So, hypotension during pregnancy is, again, associated with adverse maternal and fetal outcomes, maternal morbidity, maternal deaths, it also increases the risk of preterm birth, low-birthweight babies, stillbirths, perinatal mortality, so those are all the risks which are associated with hypertension during pregnancy in women who have kidney failure and are on dialysis.

One of the strategies which has shown to be effective is, of course, good control of blood pressure. The more recent guidelines recommend targeting blood pressure less than 140 millimeters of mercury (mmHg) and diastolic blood pressure less than 90 mmHg, so we should try to have a good control of blood pressure and we should use those medications which are safe to be used during pregnancy which includes use of labetalol or use of nifedipine. Those are the 2 most common medications which are used to treat hypertension during pregnancy for women who have kidney failure.

Pharmacy Times: Outside of dialysis, what are some specific treatment options available to pregnant individuals with hypertension? What should pharmacists know about these treatments?

Shah: Yeah, so pharmacotherapy is available outside dialysis. The 2 most common medications which we use are nifedipine and labetalol, which are used to control blood pressure for these women. They are safe to be used during pregnancy, they are not associated with any teratogenicity. One thing which we have to remember is to make sure they are not on teratogenic medication—so like angiotensin-converting enzyme inhibitors, angiotensin receptor blockers—they have teratogenicity, so they should not be used in these patients. Also, atenolol is associated with intrauterine growth restriction, so that should not be used in these patients when they are pregnant and are on dialysis.

Pharmacy Times: Are there recent advancements or emerging technologies that have improved the ability to monitor and care for pregnant individuals with kidney diseases on dialysis? How do these impact treatment decision-making?

Shah: So, there have been some advancements in this area. Though, still a lot of research is needed. One of them is awareness that women on dialysis can get pregnant, because in the past, it was believed that they are infertile, and they cannot get pregnant, so that awareness is there.

The other thing is diagnosis of preeclampsia during pregnancy. We had a recent approval of the test [that] measures the biomarker sFlt-1, and now that can be done during pregnancy and if it is above a certain threshold, it indicates higher risk of preeclampsia and these women so that can be done.

And the third thing which we have seen is effective is just intensification of hemodialysis, so all of the women who are pregnant and on dialysis should be receiving 6 hours a day of dialysis treatment for 6 days a week if possible.