Hemodialysis Initiation During Pregnancy for Advanced CKD Due to ANCA-Associated Glomerulonephritis

Introduction: Initiation of dialysis during pregnancy is uncommon. Here we describe a woman with advanced CKD due to ANCA-associated glomerulonephritis (GN) requiring initiation of hemodialysis in the early third trimester of pregnancy. Case Description: A 37-year-old woman with hypertension, rheumatoid arthritis, and CKD stage 4 secondary to ANCA-associated GN in remission for six years presented with an unplanned pregnancy. Pre-pregnancy medications included rituximab (for RA) and losartan, both stopped at pregnancy diagnosis. Labs during early pregnancy: Creatinine (Cr) 2.24 mg/dl (eGFR 28), BUN 35 mg/dl, Hb 8.9 g/dl, UACR 0.56 g/g, 2+ hematuria. At 32 weeks, she was admitted for intrauterine growth restriction (IUGR) and worsening renal function. Her blood pressure was 125/79 mmHg on nifedipine and labetalol. Admission labs revealed Cr 3.04 mg/dl (eGFR 20), BUN 40. ANCA serologies were negative. Urine prot:cr ratio was 2.9 g/g without hematuria. She was diagnosed with intrauterine growth restriction. At 32 weeks 3-day gestation, she started hemodialysis 6 days/week for 5-6 hours per session. She was diagnosed with pre-eclampsia with severe features based on severe-range blood pressure despite antihypertensive therapy. Labor was induced at 34 weeks, resulting in a vaginal delivery with favorable maternal and fetal outcomes. Postpartum, she was discharged on home hemodialysis (4 days/week) and then transitioned to peritoneal dialysis with plans for kidney transplantation. Discussion: CKD is associated with adverse pregnancy outcomes, including preeclampsia, preterm birth, IUGR, and pregnancy loss. Experts recommend initiating dialysis in pregnancy when the eGFR <20 or BUN >50–60 mg/dl—earlier than in non-pregnant patients. Hladunewich et al showed that intensive HD (>36 hrs/wk) in a Canadian cohort resulted in improved pregnancy outcomes as compared with conventional HD. Asamiya et al. found that maintaining BUN <49 mg/dl correlated with higher birthweight and gestational age at delivery among pregnant patients on dialysis. However, most patients in these studies were on dialysis before conception, with limited data on those who initiated dialysis during pregnancy. More research is required to guide timing and intensity of dialysis initiation during pregnancy.