Chan W S, Okun N, Kjellstrand C M
Department of Medicine, University of Alberta, Edmonton, Canada.
Int J Artif Organs. 1998 May;21(5):259-68.
Pregnancy is uncommon in end-stage renal failure, particularly in patients requiring dialysis. We reviewed the literature from 1965 to date, seeking an optimal way of dialyzing pregnant women after encountering one such patient
We searched the English literature by cross-referencing "pregnancy" with "hemo-" or "peritoneal dialysis" and "renal failure". Eighty-six pregnancies worldwide were found to which we added one case of our own. Various independent factors were studied against gestational age at delivery using uni- and multivariate analysis. These factors included mother's age, previous delivery, diagnoses of renal disease, dialysis duration prior to pregnancy, gestational age at onset of dialysis, dialysis type, level of hemoglobin during pregnancy, BUN and creatinine targets, BUN/creatinine ratio, dialysis intensity at the beginning and end of pregnancy, influence of erythropoietin and dialysis complications.
Of the 87 pregnancies, 12% resulted in stillbirths, 9% of neonates died prior to discharge. The mean gestational age at delivery was 32 +/- 5 weeks, and the mean birth weight 1604 +/- 652 g. Two congenital abnormalities and one twin pregnancy were reported. 48% of deliveries were premature. Pre-eclampsia was reported in 11%, and worsening hypertension in 17%. CAPD was used in 25 and hemodialysis in 62 patients. Fetal survival was similar in both cases (72% vs 82%), although incidence of various dialysis complications differed. The conventional dialysis goals of a low target BUN level and hemoglobin for pregnant patients were not factors in predicting fetal outcome. The number of hemodialyses/week were negatively correlated (R = -0.35, P = 0.061), but the hours of dialysis positively correlated (R = 0.42, p = 0.035) to gestational age. Fetal survival was independently influenced by creatinine level [564 micromol/L when baby survived vs 788 micromol/L when baby died (p = 0.021)], BUN/creatinine ratio (50 vs 30, p = 0.053), and hours of dialysis (5.6 hrs vs 3.6 hrs, p = 0.013). There was no relation of either frequency or volume of peritoneal dialysis exchanges to gestational age or fetal survival.
Greater attention to a high intake of protein (>1.5 g/kg) and higher dose of hemodialysis, achieved by longer, every other day dialysis, may be the optimal approach to pregnant patients on hemodialysis. Our first attempt to define the goal of hemodialysis is to keep the predialysis creatinine below 600 mmol/L and the protein intake high enough so the predialysis BUN level is >25 mmol/L. There are no clear guidelines on how to best perform CAPD.
妊娠在终末期肾衰竭患者中并不常见，尤其是在需要透析的患者中。在遇到一位此类患者后，我们回顾了1965年至今的文献，以寻找透析孕妇的最佳方法。
我们通过将“妊娠”与“血液”或“腹膜透析”以及“肾衰竭”交叉引用，检索了英文文献。在全球范围内发现了86例妊娠病例，并加入了我们自己的1例病例。使用单因素和多因素分析，研究了各种独立因素与分娩时的孕周之间的关系。这些因素包括母亲的年龄、既往分娩史、肾脏疾病诊断、妊娠前透析时间、透析开始时的孕周、透析类型、孕期血红蛋白水平、尿素氮和肌酐目标值、尿素氮/肌酐比值、妊娠开始和结束时的透析强度、促红细胞生成素的影响以及透析并发症。
在这87例妊娠中，12%导致死产，9%的新生儿在出院前死亡。分娩时的平均孕周为32±5周，平均出生体重为1604±652克。报告了2例先天性异常和1例双胎妊娠。48%的分娩为早产。11%的患者报告有先兆子痫，17%的患者有高血压加重。25例患者使用持续非卧床腹膜透析（CAPD），62例患者使用血液透析。尽管各种透析并发症的发生率不同，但两种情况下胎儿的存活率相似（72%对82%）。对于孕妇，传统的低目标尿素氮水平和血红蛋白的透析目标并不是预测胎儿结局的因素。每周血液透析次数与孕周呈负相关（R=-0.35，P=0.061），但透析时长与孕周呈正相关（R=0.42，P=0.035）。胎儿存活率独立地受到肌酐水平[婴儿存活时为564微摩尔/升，婴儿死亡时为788微摩尔/升（P=0.021）]、尿素氮/肌酐比值（50对30，P=0.053）和透析时长（5.6小时对3.6小时，P=0.013）的影响。腹膜透析交换的频率或容量与孕周或胎儿存活率均无关系。
对于接受血液透析的孕妇，更加关注高蛋白质摄入量（>1.5克/千克）和更高剂量的血液透析，通过延长透析时间、隔天透析来实现，可能是最佳方法。我们首次尝试定义血液透析的目标是使透析前肌酐低于600微摩尔/升，蛋白质摄入量足够高，以使透析前尿素氮水平>25毫摩尔/升。关于如何最佳地进行持续非卧床腹膜透析，目前尚无明确的指导原则。
