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Caring for Dialysis Patients During Pregnancy: Q&A with Dr. Ramy Hanna and Renate Sundelin, MSW
In this Q&A, Dr. Ramy Hanna, a nephrologist with University of California, Irvine, and Renate Sundelin, a clinical social worker with Fresenius Kidney Care, discuss their experiences treating pregnant patients with kidney failure and recent findings from several new studies on dialysis and pregnancy.
Q: There have been recent studies focusing on pregnancy in dialysis patients, such as the study published in The Journal of the American Society of Nephrology finding that more intensive dialysis has improved pregnancy rates and dramatically improved pregnancy outcomes. What is most exciting about new studies like this and what have we learned?
RH: It is exciting that studies are showing great outcomes for dialysis patients who are pregnant. We are getting better at dialysis to support pregnancy. It is by no means a risk-free proposition, but according to Sachdeva et.al. (Clin Kidney J 2017), more intensive dialysis can lead to improved birth weights and survival, though the nearly 44 percent rate of pre-eclampsia, a complication of pregnancy in patients with high blood pressure and kidney disease, remains a concern. With dialysis patients, there are long periods of time during the day when they do not have regulated blood pressure. They require two to three hours of dialysis in order to manage their volume so their blood pressure does not increase dangerously. It is important there is no risk added to an already at-risk vascular system, and that there are no outcomes like a heart attack or stroke. It is a fine balancing act to make sure the blood pressure is controlled for both the patient and the baby.
Q: Another study in The Journal of the American Society of Nephrology revealed that pregnancy is not that uncommon in dialysis patients, with pregnancies occurring in 18 out of 1,000 patients. This bring us to your patient, Adrienne Guest, who needed to start dialysis after becoming pregnant. With Adrienne being the second new mom in your clinic to deliver a baby, how do you and your team approach treatment for expecting mothers?
RH: University of California Irvine has long been a center of excellence for care of pregnant patients on dialysis, with about one pregnant patient per year. This is in large part due to the pioneering work of Dr. Kamyar Kalantar-Zadeh and our previous chief, Dr. Madeline Pahl, combined with the partnership that we share with Fresenius Kidney Care. Regarding pregnancy safety, our care team gives attention to blood pressure management, volume management, dialysis, and medication management, to ensure that successful pregnancy outcomes for a patient on dialysis are possible. It remains an art that takes an incredibly skilled physician, health system, and a savvy patient to get through a pregnancy on dialysis successfully. In Adrienne’s case, the partnership that we had with her care team at Fresenius Kidney Care University Dialysis Clinic of Orange was incredibly important. From the time when she first became a patient at the clinic, the care team, led by Medical Director Dr. Kalantar-Zadeh and Clinic Manager Miguel Hernandez, RN ensured that Adrienne received the intense personalized care needed.
SUNDELIN: Shortly after becoming pregnant, Adrienne had to begin dialysis in center at Fresenius Kidney Care, where Dr. Hanna is a part of the care team. When Adrienne experienced pregnancy complications, and was admitted to the hospital, Dr. Hanna provided her dialysis treatments for the remainder of her pregnancy in the hospital. Having that continuity of care was beneficial for Adrienne. After she had her baby, and once she was ready to be back in the center, Adrienne was happy to have Dr. Hanna continue managing her care.
Overall, the pregnant women I have worked with are resilient. Without dialysis, pregnant women are fatigued, and so by adding the additional complications that accompany dialysis, there can be many difficulties facing these women. Knowing this, I always increase my time with dialysis patients who are pregnant, ensuring that they stay at the top of my list.
Q: In Adrienne’s case, how often did she need dialysis?
RH: Most weeks, she had six days of dialysis treatment, to allow her to have one day off. Some days, the need arose, whether due to bio-chemical or blood pressure issues, where she required seven days of dialysis. To give perspective, our typical end stage renal disease (ESRD) population has dialysis three times a week. For Adrienne, we had to keep an eye on her platelet count and blood pressure, developing a system for giving blood pressure medications on an as-needed basis. There were many moving parts that went into her care, and we had to keep a close eye on everything to ensure that she had the best outcome. When treating a dialysis patient who is pregnant, it is the epitome of personalized medicine. What also helped was Adrienne's focus on having a successful pregnancy. Hard work and discipline are always the key ingredients to success. Also, there was good communication between Adrienne and me, which contributed to a favorable outcome despite the challenges.
SUNDELIN: Adrienne is a very bright and positive woman with an awesome sense of humor. One big challenge that Adrienne faced was after having her baby, when in the first few months the baby was awake during the night, and asleep for most of the day. Having her schedule disrupted was challenging at the time, yet she got through it, and was always able to smile and crack a joke. Her optimistic outlook has always made her a great patient.
Q: Another recent study from The Journal of the American Society of Nephrology suggests that many women on dialysis want to get pregnant. For those patients wanting to become parents, what advice do you have for them?
RH: Be a good dialysis patient first. Attending your appointments on time is important, as well as making sure you manage your fluids. It is best to consider pregnancy while you still have native kidney function. When people are earlier in the course of loss of kidney function, there is urinary output, and so it is ideal if a patient is considering pregnancy in their first couple of years in dialysis while some residual kidney function is retained. When someone has been on dialysis for a long time, the risks can increase.
SUNDELIN: When dialysis patients are pregnant, I encourage them to verbalize whatever they are feeling. It is important to process their feelings so that we can provide support they need. I am also always looking for community resources for patients, as many have challenges in addition to their dialysis.
About Dr. Ramy Hanna:
Ramy Hanna, MD FASN FACP FNKF, is currently an Assistant Professor at UC Irvine Department of Nephrology Hypertension and Renal Transplantation. Dr. Hanna is an assistant professor of nephrology at UCLA and UCI. He completed training at Olive View UCLA Medical Center in internal medicine and nephrology. He serves as an associate medical director, associate director of inpatient dialysis at UCI medical center, and assistant fellowship program director of the UCI nephrology fellowship.
About Renate Sundelin:
Renate Sundelin MSW, LCSW, is a trilingual Clinical Social Worker at Fresenius Kidney Care University Dialysis Clinic of Orange with more than 20 years of experience in social work. Renate received her Master’s Degree in Social Work from Humboldt State University in 2017, and has worked on the Interdisciplinary Team at Fresenius Kidney Care since that time. At Fresenius Kidney Care, Renate works with the whole care team to help create positive and personalized patient experiences