Dialysis and Pregnancy: Optimizing Therapy for Best Maternal and Fetal Outcomes

Pregnancy in women with end-stage kidney disease (ESKD) requiring dialysis remains high risk, with significant maternal and fetal complications. While fertility rates are markedly reduced in this population, advances in dialysis care and obstetric management have led to increasing reports of successful pregnancies. Important maternal adverse outcomes include early pregnancy loss, preeclampsia, polyhydramnios, and cesarean delivery, while common adverse fetal outcomes are preterm birth, low birth weight, and high neonatal intensive care utilization. Evidence consistently demonstrates that dialysis intensification-achieving longer treatment hours or targeting lower maternal blood urea nitrogen levels-correlates with improved gestational age and birth weight, thereby enhancing live birth rates. Optimizing therapy further requires individualized dialysis prescriptions, careful volume and blood pressure management, and timely adjustment of dialysate composition. A multidisciplinary approach involving nephrology, maternal-fetal medicine, obstetrics, gynecology, and neonatology is critical for care coordination. Despite these advances, significant disparities persist, particularly in access to intensive dialysis and specialized care worldwide. Future directions include strengthening obstetric nephrology training, expanding research in peritoneal and home hemodialysis during pregnancy, and establishing integrated care models. With careful planning and optimization of renal replacement therapy, maternal and fetal outcomes in this high-risk population can continue to improve. This review aims to synthesize current evidence on fertility, dialysis strategies, and maternal-fetal outcomes in pregnant women with ESKD on dialysis, while highlighting practical considerations for dialysis optimization and multidisciplinary care, thereby addressing gaps in consolidated guidance for clinicians managing this increasingly encountered high-risk population.