A 36-year-old woman, gravida four, para three, with ESRD presumed secondary to diabetes in the absence of a biopsy, initiated on hemodialysis eight months prior, presented to the emergency room with one week of intermittent abdominal pain, nausea and vomiting, and was found to be 8 weeks pregnant by ultrasound dates. Her past medical history included insulin-dependent diabetes mellitus for 11 years associated with mild proliferative retinopathy and hypertension requiring multiple medications. Her surgical history was significant for three prior term cesarean sections. Given the increased risk of maternal mortality and fetal complications associated with pregnancy in ESRD, she underwent intensive counseling and ultimately elected to continue with the pregnancy. At that point, her dialysis regimen was intensified to a regimen consisting of 24 h/week (four hour treatment sessions on six days per week). Dialysate composition consisted of potassium 4 mmol/L, bicarbonate 25 mmol/L, calcium 1.25 mmol/L and sodium 140 mmol/L. The dialysate was supplemented with an IV infusion of potassium phosphate 30 mmol with each dialysis run, on account of persistent hypophosphatemia from poor oral intake and intensive dialysis. Dialysate flow was 800 ml/min, and blood flow was 400 ml/min via a left upper extremity AV fistula. Her mid-week standardized Kt/V was 1.42 (range 1.26–1.59). She was anticoagulated with unfractionated heparin. Her medications consisted of labetolol 100 mg twice per day, prenatal multivitamin one tablet daily, folic acid 1 mg daily, vitamin B6 100 mg daily, calcium carbonate 1,250 mg with meals, erythropoietin IV three times a week (TIW) to keep hemoglobin levels between 10 and 11 g/L, IV iron supplementation according the dialysis unit anemia management protocol (total 1,200 mg in nine months) and oral calcitriol 0.25 mg TIW.
Weeks after her pregnancy was discovered, she continued to have abdominal pain and vomiting requiring hospitalization; further workup of elevated serum liver enzyme levels including an abnormal abdominal ultrasound revealed cholelithiasis with acute cholecystitis. Due to heightened surgical risks associated with pregnant patients, initial management of the acute disease was conservative, with bowel rest and IV hydration. She continued suffering from recurrent attacks of abdominal pain and vomiting, with continual inability to maintain appropriate caloric intake, and persistently elevated serum liver enzyme levels. At 14 weeks of pregnancy, her estimated dry weight (EDW) was 71.5 kg, a 5.5 kg loss compared to her pre-pregnancy dry weight of 76 kg (155% IBW, BMI = 31.1 kg/m2
) and her nutritional protein catabolic rate (nPCR) was only 0.55. Intradialytic parenteral nutrition (IDPN) was thus initiated. Her estimated nutrient requirements were 2,100–2,250 kilocalories (kcal) [1
REE × 1.2–1.3 + 300 kcal for pregnancy] and 75–85 g protein [2
MAW × 1.4–1.5]. The IDPN provided 95 g of protein (15% amino acids, 380 kcal), 100 g dextrose (340 kcal) and 40 g of lipid (400 kcal) for a total of 1.5 calories/ml and 1,120 kcal per bag. She received one bag of IDPN at each dialysis session. At 18 weeks of pregnancy, she underwent laparoscopic cholecystectomy without complications for persistently symptomatic cholecystitis.
After surgery, her liver enzymes normalized, yet she continued to experience intractable nausea and vomiting for two subsequent months without a clear etiology. While she was unable to reliably complete calorie count questionnaires, she would always remark on her inability to consume a normal meal and her serum phosphorous levels declined even further than expected for her intensive dialysis regimen. Furthermore, her weekly ultrafiltration requirements remained extremely low, averaging 1.1 L per week, further confirming her very poor PO intake. She was thus diagnosed with severe hyperemesis gravidarum and was unsuccessfully treated with anti-emetics. She continued to have poor appetite and weight loss until week 26 of her pregnancy, when her EDW stabilized between 72 and 74 kg, rather than continuing its downward trajectory.
For the remainder of her pregnancy, she was maintained on IDPN, the frequency of emeses decreased, and she started to eat more regularly. Her EDW slowly increased, demonstrating true weight gain, as she never developed any edema or other signs of increased extracellular volume. While her albumin never improved, her pre-albumin did increase with time, up to 33 mg/dL at week 29. In addition, her nPCR rose, from a nadir of 0.55 at week 12 of pregnancy prior to starting IDPN, to a height of 1.65 at week 20. For comparison, her pre-pregnancy nPCR was 1.23.
Fetal monitoring occurred with frequent, serial ultrasounds. Despite poor maternal nutrition, obstetric ultrasounds at 17, 29 and 33 weeks of gestation revealed normal fetal weight for gestational age. Polyhydramnios was noted on ultrasound at week 33, and given the ongoing risk of maternal and fetal complications, including fetal demise; she was admitted to the hospital for a cesarean delivery at 36 weeks of gestation after undergoing an amniocentesis for fetal lung maturity. The female neonate weighed 3,505 g, with Apgar scores of 7 and 9.