Chronic kidney failure, or end-stage renal disease (ESRD), requires renal replacement therapy like hemodialysis (HD) or peritoneal dialysis (PD). Dialysis filters waste products and excess fluid from the blood. While many women on dialysis face fertility challenges, conception is possible, though it places both the mother and the developing fetus into a high-risk medical category. The medical community now manages these pregnancies with specialized, intensive treatment protocols to increase the likelihood of a successful live birth.
Fertility Status and Conception Challenges on Dialysis
Women with ESRD commonly experience significantly reduced fertility due to the physiological effects of kidney failure. The chronic buildup of uremic toxins and the disruption of the endocrine system inhibit normal reproductive function. Many women on dialysis experience amenorrhea (absence of menstrual periods) or oligomenorrhea (infrequent menstruation).
This menstrual irregularity stems from a disruption of the hypothalamic-pituitary-gonadal axis. High levels of the hormone prolactin (hyperprolactinemia) occur because the failing kidneys cannot clear it effectively. Elevated prolactin suppresses the pulsatile release of other hormones necessary for ovulation. Even when a woman does have a period, the cycles are often anovulatory, further decreasing the chance of pregnancy. Despite these challenges, reduced fertility does not equate to sterility, and women of childbearing age on dialysis should still use reliable contraception if they wish to avoid pregnancy.
Risks to Mother and Fetus During Dialysis Pregnancy
A pregnancy carried while on dialysis is considered high-risk, presenting complications for both the mother and the fetus. Maternal risks include severe hypertension (reported in up to 80% of these pregnancies) and preeclampsia, a dangerous complication characterized by high blood pressure and organ damage that occurs in 5% to 40% of cases. Fluid overload is a constant threat because the kidneys cannot regulate the increased volume of pregnancy. Anemia, already a common issue in ESRD, can worsen and pose further risks to the mother and the fetus.
Fetal outcomes are concerning, with a high rate of preterm birth being the most common complication. Up to 80% of these pregnancies historically resulted in delivery before 37 weeks gestation. The fetus also faces a risk of intrauterine growth restriction (IUGR), meaning the baby does not grow to the expected size due to impaired placental function. Furthermore, the risk of fetal loss, including stillbirth and miscarriage, is substantially higher than in pregnancies where the mother has normal kidney function.
Adjusting Dialysis Treatment for a Successful Pregnancy
Once a woman on dialysis is pregnant, the treatment regimen must be intensified to improve the outcomes for the fetus. The traditional schedule of three dialysis sessions per week is insufficient for managing the increased metabolic demands of pregnancy and the waste products from the developing fetus. Intensive dialysis is required, meaning increasing hemodialysis frequency to five or six sessions per week, with a total weekly duration often exceeding 36 hours.
The primary goal of this intensified schedule is to maintain the pre-dialysis blood urea nitrogen (BUN) level below 35 mg/dL, as lower BUN levels are strongly linked to better fetal outcomes, including higher birth weight and longer gestational age. This more frequent treatment helps control maternal blood pressure and fluid status, which are essential for placental health. Medication adjustments are also required; for example, the dose of erythropoietin, used to manage anemia, is often increased by 50% to 100% to maintain a target hemoglobin level. Antihypertensive medications must be carefully selected, avoiding common drugs like ACE inhibitors and ARBs, which are known to harm the developing fetus.
Post-Delivery Outlook and Long-Term Health Considerations
With the implementation of intensive dialysis, the live birth rate for women on dialysis has improved, reaching as high as 85% or more in recent cohorts. Despite this success, the average gestational age at delivery remains relatively early, often between 32 and 36 weeks, meaning the infant will likely be premature. Consequently, immediate specialized care in a neonatal intensive care unit (NICU) is often necessary for the newborn.
The mother’s recovery involves continued close monitoring, and the dialysis prescription may be gradually reduced to pre-pregnancy levels once the acute demands of gestation are over. For the mother’s long-term kidney health, pregnancy generally does not cause a permanent worsening of kidney function unless she had poorly controlled high blood pressure before or during the pregnancy. The prognosis for the child’s long-term development is good, though the risks associated with prematurity, such as developmental delays, must be considered and monitored throughout childhood.