A case study of two successful pregnancies in a patient with end-stage renal disease

CASE STUDIES

A Case Study of Two Successful Pregnancies in a Patient With End-Stage Renal Disease JoanBrookhyser,RD, CD,* Carol Kinzner, BSN, RN, CNN,f and StevenPahre,BS, BPharm, RPh# Pregnancy in the patient with end-stage renal disease is a rare event in part due to the multitude of endocrinological abnormalities. Bringing a pregnancy to its successful conclusion requires the involvement of many health care professionals, including the nephrologist, dietitian, pharmacist, and nurse. The perspectives ‘of the dietitian, pharmacist, and nurse of one such patient who has had two separate successful pregnancies is reviewed. o 1996 by the National Kidney Foundation, Inc.

S

UCCESSFUL PREGNANCY in patients with end-stage renal disease (ESRD) involves the combined efforts of many health care professionals when considering the several facets of care involved in such situations.1-4 Presented is a case report of the team management for a woman, A. L., who had two successful births while on hemodialysis. The perspectives of the dietitian, pharmacist, and nurse are reviewed as an important part in the management of this high-risk patient. Because of the multitude of endocrinologic abnormalities in women on hemodialysis, pregnancy is rare, with only 0.9% of women on hemodialysis becoming pregnant.5 Most women with ESRD who do conceive have residual function and conceive before the initiation of dialysis treatment. Miscarriages have been reported to occur in 11% to 54% of these pregnancies.5,6 The pregnancies of A. L. were unique in that the conceptions were planned by the patient

*Renal Dietitian, Nephrofogy Sewues, Saint Joseph Medical Center, Tacoma, WA. fNephrology Educator, Nephrology Services, Saintjoseph Medical Center, Tacoma, WA. #Renal Pharmacist, Nephrology Services, Saint Joseph Medical Center, Tacoma, WA. Address reprint requests to Joan Brookhyser, RD, CD, Sarntjoseph Medtcal Center, PO Box 2197, Tacoma, WA 98401. 0 1996 by the National Kidney Foundatcon, Inc. 1051-2276/96/0601-0005$03.00/O

26

compared with many pregnancies documented in ESRD literature that ‘)ust happened.” As a result, pharmacological factors, diet, and dialysis dose parameters were monitored closely before conception and during gestation. Medications were evaluated for teratogenicity, diet was emphasized for caloric and protein quality, and hemodialysis treatments were prescribed for optimum health as well as potential for improving hormones and fertility by maintaining a consistent Kt/V greater than 1.4.

Medical

and Surgical

History

A. L. was diagnosed with chronic interstitial nephritis at the age of 20 years and started hemodialysis in July 1990 at the age of 23 years. Her first pregnancy occurred 3 years after the initiation of hemodialysis treatments, and her second pregnancy started 11/z years after the birth of the first infant. She continued to have a moderate residual urea clearance of 1 to 2 mL/min until the last part of her second pregnancy when her function decreased to 0.5 mL/min residual urea clearance. Because of a rapid increase in parathyroid hormone levels after her first pregnancy, a partial parathyroidectomy was performed in September 1994.

Laboratory

Data

Several of A. L.‘s blood chemistries required monitoring for nutritional, pharmacological, Journal

ofRenal Nutrition,

Vol6,

No 1 (January),

1996: pp 26-33

PREGNANCY

AND

ESRD:

and nursing management. These parameters are summarized in Table 1 and will be referred to frequently throughout the article.

Nutritional

1. Laboratory

Management

Data and Goals

Chemistry BUN (mmol/L)

[w/W

27

STUDY

lines for moderating her fat and cholesterol intake were provided for preventative health care purposes. Fluid gains of 1 to 2 kg were maintained easily during her pregnancies with a “liberal” fluid intake (approximately 40 oz/d). Liberal fluid intake in this situation is not uncommon because of the frequency of dialysis and subsequent fluid removal. Based on her albumin levels, diet history, and normalized protein catabolic rate (NPCR), A. L. appeared to be maintaining good protein stores with an intake of more than 70 g of protein/d during her first pregnancy. During her second pregnancy, her diet history indicated that her protein intake was not adequate ( < 70 g/d), and subsequently her albumin levels decreased (Table 2). Her NPCR remained higher than 1.0; however, validity of the NPCR as a measure of adequate protein intake is questionable in the pregnant ESRD patient because of ana-

Diet restrictions can be liberalized in the pregnant woman with ESRD because of the increased frequency of hemodialysis treatments.js4 However, ongoing monitoring for excesses and deficiencies related to diet and blood chemistries are still needed. Before her first pregnancy, A. L. weighed 5 1.5 kg and was 86% to 97% of her ideal body weight. She gained 15.8 kg during her first pregnancy and 17 kg during her second pregnancy (Fig 1). She gained weight during both pregnancies at an appropriate rate and consumed 1,700 to 1,900 kcal/d. Her cholesterol levels tended to increase in the last trimester of both pregnancies, which is not uncommon during normal pregnancy.‘O However, guideTable

A CASE

Goals

Pregrawd Average 1 Year Before BecomIng Pregnant (12191.12/92)

During Fwst Pregnancy (12/92-E/93)

Postpartum First Pregnancy (Average for Year FolIowIng) (E/93-9/94)

During Second Pregnancy (11/94-7/95)

Postpaltum Second Pregnancy (Average for Year Followmg) (6/95)

< 22 [ < 601 pregnancy <37 I< 1001 postpartum

26.20 [79]

22.13 [62]

27 13 [76]

19 64 [55]

23 21 [65]

2 74 [lo 5-11.01

2 70 [lo 6)

270[106]

2 40 (9 61

2.32 [9 31

2 12 16.51

35-55 [3 55

39 [3 91 (K-2 concentrate)

49 [4.9] (K-2 concentrate)

42 [4.2] (K-l concentrate)

50 151 (K-l concentrate)

14%194[45-6]

2 42 [7 51

1 20 [3 71

2 10 [6.5]

1 42 [4 41

2 42 [7 51

<76 [<300] < 50 NPTH < 200 IPTH

4.76 1641 20 NPTH

6 32 [320] 71 NPTH

7 44 [266] 1129 IPTH

7 07 [272] 76 IPTH

9.10 [350] 336 IPTH

35 [35]

.30 [30]

26 [26]

35 1351

30 (30 (2236)]

40 [40]

20

44

29

26

30

20

>100[>100] IO-55

426 [426] 24

66 [66] NA

113 {I131 NA

132 [I321 77

111 [ill] II

>35[>35]

45 [4 51

39 [3 91

46 1461

35 [3 51

44 [4 41

>06’ >1.4

1 09 1 4-1.6

97 1 9-2 1

1 15 1 2-1 4

99 1 16-2.37

11 1.7

Calcum (mmolii)

[WdLl Potassum (mmol/L) [mEq/dL] Phosphorus

51

50 [5.0] (KG2 concentrate)

(mmolil)

WwIdU Cholesterol (mmol/L)

ha/dU Patathyrold (n-terminal v Intact)* (pgiml) Hematocrlt (L)

WI Iron studies % Saturation FerntIn (mmol/L) InglmU 25-hydroxycholecalc#ferol @g/ml)’ AlbumIn wa bromcreosol purple method (g/L)

[g/W NPCR’ KtiV (Fresenws Pack H Program analysis)

Abbreviations SUN, blood urea nitrogen; NPTH, N-terminal parathyrold hormone level. IPTH, parathyrotd normalwed protein catabolic rate, ESRD, end-stage renal disease, NA, not avaIlable *Recommendations for pregnant ESRD patients do not exist the goals lksted are based on ckmcal expernence tFresnws USA, Walnut Creek. CA Datafrom Ho~,~Brookhyserand Pahre.aand Wllkens and Schlro 9

hormone

level by radIoimmunoassay,

NPCR,

28

BROOKHYSER,

KINZNER,

AND

PAHRE

B

17 16

16

16

15

14

14

13

13

12

12

11

z 11 x10 .E tag ;8 .o, a 7 '6

El0 +j

9

;8 .9 a,7 '6 5 4

_...............-......... - _....._... .- .._........ -. .._... $ _.--.

I' 5

/I

5

I

4

..-

3

3

a

2

2

1

1 0

0

6

12

18

24

30

i~,i,,:,,i,,,,,i,,,,,i,‘,,,i,,,,,i

0

36

6

12

18

24

30

36

Weeks Gestation

Weeks Gestation

Figure 1. A. L.‘s weight gain during pregnancy. Height = 152.8 cm; ideal body weight = 53 to 59 kg. (A) Pregravid weight = 51.5 kg; weight at delivery = 67.3 kg. I = normal;llll = first pregnancy. (B) Pregravid weight = 51.5 kg; weight at delivery = 68 kg. I = normal; 1111 = second pregnancy.

bolic status and unstable nitrogen balance. A. L. was started on one Regain bar (NC1 Medical Foods, Irwindale, CA) daily, which provided an additional 15 g of protein and 330 kcal to improve her protein intake. By using this nutrition supplement, she was able to meet her protein goals.

Vitamins During her first pregnancy, A. L. received a multivitamin/nutritional supplement, CarniVite (Vitaline, Ashland, OR), at two tablets per Table

2. Summary

of Nutrient

day. This was prescribed based on the recommended guidelines for a pregnant hemodialysis patient.4Jj*9 This vitamin was discontinued by the manufacturer and therefore was not available during her second pregnancy. Because this formulation worked well during her first pregnancy, the authors tried to duplicate it with two Nephrovite (R & D Laboratories, Marina de1 Ray, CA) tablets per day and an oral carnitine supplement. These prescribed supplements as well as their composition are listed in Table 3. Because adequate zinc supplementation was not

Intake and Goals

Nutrient

Recommended for ESRD Pregnancy

kcal Protein (g) Sodium (mg) Potassium (mg) Phosphorus (mg) Cholesterol (mg)

BEE x 1.2 + 300 = 1,920 1 g/kg IBW + 10 g = 63-69 Liberal Liberal 1,200-l ,500 < 400

Recommended for Non-ESRD Pregnancy BEEx1.2=300 0.6 g/kg + 10 Liberal Liberal Liberal Liberal

Intake During First Pregnancy (Amounts per Day)

Intake During Second Pregnancy (Amounts per Day)

1,700-l ,900 60-70 2,000 2,400 1,500 200

1,700-l ,900 60-70 1,600 1,900 1,000 200

Abbreviations: ESRD, end-stage renal disease; BEE, basal energy expenditure; IBW, ideal body weight. Data from Wilkens and Schiro.g

29

PREGNANCYANDESRD:A CASESTUDY Table 3. Vitamin and Mineral Recommendations and Comparisons Daily Recommended Intake

Vitamins Vitamin C (ascorbic 6, (thiamin) BP (riboflavin) B3 (niacin) Bs (pyidoxine) B12 (cyanocobalamin) Pantothenic acid Biotin Folic acid Zinc Iron Levocarnitine Vitamin D

acid)

200 mg 3.0 mg 3.6 mg 40 mg

60 mg 1.5 mg 17mg 20 mg 10mg

10mg NA NA

6w 10mg

600 pg 2.0 PLQ 20 mg Variable NA Monitor

Nephrovite

300 I4 600 w

Carnivite

Niferex

Calcitriol

Levocarnitine

60 mg 5mg 5mg 30 mg 10mg

6 i-s! 20 mg 3OOla 600 w 20 mg 150 mg

330 mg

500 mg

0.25 pg

levels

Abbreviation: NA, not available. Data from Hou and Grossman.6

present in her supplements, and oral zinc supplementation caused her gastrointestinal upset, she supplemented her diet with the cereal Just Right (Kellogg, Battle Creek, MI), which provided 15 mg of zinc per serving (75% of the Recommended Dietary Allowance) to meet her recommended needs (11). Her 25-hydroxycholecalciferol levels were normal (24 ng/mL), but she was given oral calcitriol to maintain these stores. Intravenous (IV) calcitriol was discontinued because of the lack of information about its use in pregnant women on hemodialysis.

Iron Therapy and Erythropoietin Alfa Dosing During her first pregnancy, iron stores were maintained well with oral supplementation, ferrous sulfate twice daily, and IV recombinant human erythropoietin (rHuEP0) dosing of 1,500 initially increased gradually up to 6,000 per treatment by her second trimester. In the second trimester of her second pregnancy, A. L.‘s hematocrit decreased to .23 L (23%). She had been taking two Niferex (Central Pharmaceuticals, Seimor, IN) tablets three times per day and was receiving 8,000 U of rHuEP0 per treatment. She was experiencing tachycardia and severe lethargy. Her stools were guaiac negative. IV iron was started at 500 mg every run for 6 weeks (after test dosing). After 1 week of treatment, her hematocrit remained low at .22 L (22%), her ferritin level was 6, and she was at 6% saturation. As a result, she was given 2 U of packed red blood cells after which her hemato-

crit increased to .28 L (28%). At this point, A. L.‘s rHuEP0 was increased to 10,000 U. She continued with that level of rHuEP0 and was able to maintain a hematocrit higher than .30 L (30%) with no further tachycardia, unusual lethargy symptoms, or ill effects until her delivery.

Pharmacological

Management

Assessment of A. L.‘s medication regimen involved a review of the literature for the potential for teratogenicity and any other potential adverse effects associated with pregnancy. The Food and Drug Administration has established pregnancy risk categories to indicate the teratogenic potential for any given medication (Table 4). The risk category for each of A. L.‘s medications is listed in Table 5. All recommendations were immediately accepted by the nephrologist. Although quinine was listed on the patient’s chart, she had not used it for quite some time. With the calcitriol there was some speculation that the supraphysiological doses normally given to ESRD patients to suppress the parathyroid gland might interfere with the fetus’ parathyroid development. For this reason the calcitriol changes were made as indicated.

Nursing

Management

There were several concerns for the nephrology nurses throughout both of A. L.‘s pregnancies. The highest priority concerns were to provide adequate dialysis, maintain hematocrit

30

BROOKHYSER,

Table

4. Food Categories

Risk

and

Drug

Risk Category

Adequate studies in pregnant women have failed to show a risk to fetus in the first trimester, and there is no evidence of risk in later trimesters Animal studies have not shown an adverse effect on the fetus, but have been no adequate clinical studies in pregnant women Animal studies have shown an adverse effect on the fetus, but there have been no adequate studies in humans; the drug may be useful in pregnant women despite its potential risks There is evidence of risk to the human fetus, but the potential benefits of use in pregnant women may be acceptable despite potential risks Studies in animals or humans show fetal abnormalities, or adverse reaction reports indicate evidence of fetal risk; the risks involved clearly outweigh potential benefits

B

C

D

X

5. Food

Medication Quinine

and and Dose

Drug

Administration

Ordered

SO4 (1 cap q4h pm)

Categories

Associated

Risk Category X

with

A. L.‘s

Pregnancy Pharmacist

Studies have shown fetal anomalies during the first trimester, with CNS (ie, hydrocephalus) and limb defects being the primary teratogenic effects The effect of vitamin D that exceeds the RDA in infants is not known; recommended maintenance dose for the management of hypocalcemic patients under chronic dialysis 0.25 kg QOD up to 0.5 kg to 1.25 kg QD.

C

rHuEP0 1,500 (10,000 U IV QHD per treatment; see text) OscalS (500 mg; 5 tabs six times daily)

C

NA

C

NA

B A A

NA OK to use OK to use

Abbreviations: cap, capsule; pm, as needed; Allowance; PTH, parathyroid hormone. *Roche, Nutley, NJ. tAbbott, Abbott Park, IL. *Smith Kline Beecham, Philadelphia, PA. §Marion Merrill Dow, Kansas City, MO. IjCentral Pharmaceuticals, Indianapolis, IN. llR & D Laboratories, Marina del Ray, CA.

PAHRE

Comments

Calcitriol (Rocaltrol* 0.25 kg 2 qd; Calcijext 0.5 pg IV qhd)

Cephulad (30 mL qd pm) Niferex(l (150, 1 cap bid 1” ac) Nephrovitell(1 tab qd)

AND

levels, and provide hemodialysis treatments that would not cause distress for the fetus as a result of hypotensive episodes. Laboratory data were obtained weekly for several parameters, one of which was hematocrit. The nurse’s role in maintaining the hematocrit at the levels determined was first to minimize blood loss in conjunction with the hemodialysis treatments. The dosage of heparin was closely monitored throughout the pregnancies, and activated clotting times were used to determine the dose. During the first pregnancy, no difficulty was incurred in minimizing blood loss and maintaining her hematocrit level with rHuEP0 and oral iron supplements, but during the second pregnancy her hematocrit decreased despite the close monitoring. At that time, the nurses administered the course of IV iron as well as the two transfusions of packed red blood cells that were ordered. Maintaining an accurate dry weight and providing treatments that factored in the weight gain of pregnancy and the need to remove

Pregnancy

Description

A

Table

Administration

KINZNER,

CNS,

central

nervous

system;

Recommendations

Discontinue; patient does not use

states

she

Discontinue Calcijext and change RocaltroI* to 0.25 pg bid in divided doses with Oscal$ to enhance calcium absorption while minimizing mother and fetus PTH suppression Continue to prevent anemic risk to fetus Continue to maintain postparathyroidectomy serum calcium goal Continue Continue Take bid (dietitian to make recommendations)

IV, intravenous;

RDA,

Recommended

Daily

PREGNANCY

AND

ESRD:

normal fluid required in ESRD patients were probably the most challenging aspects of this case for the nephrology nurses. Dry weight assessments were performed with regularity to ensure that the target weights were achieved. Every attempt was made to provide consistency of care for A. L. in that she dialyzed in the same area every day, thus minimizing the number of staff dealing with the issues. The last technique, and perhaps the most important, employed was listening to what A. L. had to say about how she felt. She was a good judge of what was occurring in her body and played a key role in the collaborative process required to assure that two infants were gorn heal&y.

Dialysis Treatment Prescription A. L. was using a cellulose acetate dialyzer (model CA1 10, Baxter Healthcare, McGaw Park, IL) before her first pregnancy and was converted to polysulfone Fresenius dialyzers (models F8 and F80M, Fresnius USA, Walnut Creek, CA) after conception. After several Kt/V evaluations and assessment of pre-blood urea nitrogen (BUN) levels, she was maintained on the F80M dialyzer to improve overall clearance of urea and improve removal of other potential harmful waste products.12-” Halfiay through her second pregnancy, she was converted to the F8 dialyzer to prevent suspected protein loss through the larger-membrane F80M dialyzer.18 See Table 6 for a summary of her dialysis prescriptions. Because of the nephrologist’s concern of vaginal breakthrough bleeding, her heparin dose was decreased from 3000 U to 2500 U during both pregnancies. As a result, her average number of reuses was 2.5 times per dialyzer. Her

Table

6. Dialysis Prescription

31

STUDY

dialyzer was disinfected with Renalin (Renal Systems of Minntech, Minneapolis, MN) and reused. The hemodialysis equipment used was volumetric in nature, thus providing good control of fluid removal during each treatment. Sodium modeling was employed with the sodium level set at 145 mEq/L for 3~2 hours and then returned to the normal sodium level of 139 mEq/L for the last M hour of the 4-hour treatment. This is a method of raising the sodium level in the dialysate to enhance fluid removal without a compensatory decrease in blood pressure as a result of the shift of fluid from the vascular space into to the tissues or through loss during dialysis. The treatment goals before conception and after birth were to keep hemodialysis adequacy, as measured by Kt/V, greater than 1.4.17 Blood for this test was drawn 2 minutes after the end of her treatment time. During her pregnancies, bimonthly BUN levels were also determined with the goal of achieving a BUN less than 21.42 mmol/L (60 mg/dL) between her longest periods without dialysis. Kinetic modeling was also performed by the dialysis staff every 2 weeks. Because adequacy of treatment based on Kt/V in pregnancy is unavailable in the literature, documentation in this article is moi-e for reference in this particular case and is not based on any previous studies or references. A Kt/V greater than 1.4 was arbitrarily set by the interdisciplinary team and maintained during both pregnancies (Table 1). These goals established for dialysis adequacy were accomplished by increasing the number of treatments per

and Urea Kinetic Data

Dialyzer Before first pregnancy During first pregnancy After first pregnancy During second pregnancy After second pregnancy

A CASE

Type

G3N* and CA1 1 Ot F80M* & F8$ CA1 1 Ot F80MS and F8$

m*

NOTE. Ureaclearance of F8 = 248 mL/min, of F80M Abbreviation: BFR, blood flow rate; HD, hemodlalysis *Cobe-Gambro, Denver, CO. tBaxter Healthcare, McGaw Park, IL. SFresnius, Walnut Creek, CA.

BFR (mL/min)

HD Time and Frequency

300 300-400 350 400 400

4 4 4 4 4

= 255 mL/min,

hr hr hr hr hr

@ 3/wk @, 5/wk @ 3/wk f& 5/wk @m 3/wk

Averaged KtlV 1.58 1.94 1.58 2.0 1.78

and of CA1 10 = 215 mL/min.

Averaged Residual Urine Urea (mL/min) 1.19 1.39 1.12 0.5 0.4

32

BROOKHYSER,

KINZNER,

week to five, with A. L. not dialyzing on Wednesdays and Sundays. Bicarbonate levels ranging from 23 to 29 mmol/L (23 to 29 mEq/L) were maintained with a standard bicarbonate dialysate of 39 mmol/L (39 mEq/L). Even though respiratory alkalosis usually is a risk in normal pregnancy and an increased risk in a pregnant hemodialysis patient, because of the frequency of dialysis6 A. L.‘s treatment plan required no adjustment in bicarbonate dialysate to maintain these levels. Potassium concentrates also required very little adjustment. She was maintained on a K-2 concentrate before and during her first pregnancy. Between pregnancies, during her second pregnancy, and after pregnancy she was maintained on a K-I concentrate without any serum potassium abnormalities (Table 1).

Complications A. L. was admitted twice during her second pregnancy for premature labor. During one of these admissions a magnesium sulfate drip, which is a common treatment to slow contractions in patients with premature labor, was started. Even though there is a risk of hypermagnesemia with this treatment in a pregnant dialysis patient, this therapy has been administered successfully in pregnant dialysis patients with careful monitoring.6 In this particular situation magnesium levels were checked and were found to be within a normal range.

Outcome and Postpregnancy

Care

A. L.‘s first pregnancy went to 36 weeks gestation and resulted in a 6 lb 3 oz boy; the second pregnancy went to 35 weeks gestation and resulted in a 6 lb 4 ounce boy. Both infants were delivered vaginally (46% of all pregnancies in ESRD patients are delivered Caesarian.5,6) A. L. chose to formula feed the infants; they are healthy and developing normally. At last examination the eldest, who is now 2 years old, was at the 50th percentile for height and weight. At 1 month the second child was at the 10th percentile for height, weight, and head circumference. Monitoring A. L. after pregnancy remained important. Areas of treatment-dry weight, dialysate potassium concentration, rHuEP0 dosing, nutritional supplementation, KU, and

AND

PAHRE

residual function-needed to be reviewed, with treatment adjustments made as needed. After the birth of A. L.‘s first child she was able to dialyze for 3.5-hour treatments 3 timeslwk with a Kt/V of 1.59. After 6 months her treatment times were decreased to 3 hours; a Kt/V of 1.2 was maintained. After her last pregnancy A. L. dialyzed for 4 hours 3 timeslwk and maintained a Kt/V of 1.78, an NPCR of 1.18, and a residual urine urea concentration of 0.4. Despite a decrease in her treatment time after giving birth, A. L. maintained a normal serum potassium level without an adjustment in her potassium concentrate or diet intake (Table 1). Her dry weight decreased by 8 kg during the first 4 weeks after her first pregnancy and by 10 kg in the first 4 weeks after her second pregnancy. She no longer required the Regain bars and was able to achieve a postpartum albumin level of 4.4. A. L. was advised to decrease the Nephrovite to one tablet per day and the iron polysaccharide to two capsules per day. Her most recent parathyroid hormone level by radioimmunoassay was 338, and plans to restart IV calcitriol are in progress at the time of writing. Even though successful pregnancies are occurring more frequently in the ESRD patient population, the care of such patients demands a great deal of attention. To date the literature is limited on erythropoietin dosing during pregnancy and devoid of information on the definition of adequacy of dialysis, dialyzer choices and reuse, and the effects of dialysis on the pregnant ESRD hemodialysis patient. This case study is presented as documentation of positive outcomes of two successful pregnancies with EPO dosing, vitamin and mineral supplementation, achieved KtlV, dialyzer use and reuse methodology, and key areas to be monitored after pregnancy in pregnant ESRD patients.

Acknowledgment The authors thank Paul Schneider, MD, nephrologlst, Washington, DC, and Roy Kuphal, MD, postdoctoral fellow, Boston University MedIcal Center, Boston, MA, for their assistance in reviewing the manuscript.

References 1 Hou S: Pregnancy and birth Dial Transplant 23:22-26.1994

control

in dialysis

patlents.

PREGNANCY

AND

2. Barri Y, Al-furayh 0, Qunibt W, et al: Pregnancy m women on regular hemodialysrs. Dial Transplant 20:652-695, 1991 3 Schiro KB: Pregnancy and hemodialysis: Nutrmon consrderations. Amertcan Kidney Foundanon Newsletter for Health Professionals 11:3- 11, 1987 4. Bakke T: Nutrmon consrderations in renal drsease: Pregnant patrent on dralysis. Dial Transplant 18:4, 1989 5. Ginsburg E, Owen W: Reproductrve endocrmology and pregnancy m women on hemodialysrs. Semm Dral 6: 105-l 16, 1993 6. Hou S, Grossman S: Pregnancy in chrome dialyses patients. Semin Dial 3:224-229, 1990 7. Hou S: Nutrmonal problems m the pregnant dialyses patient. Lecture grven at the NKF Clinical Nephrology Meetmg, Chrcago, IL, April 1994 8. Brookhyser J, Pahre S: Dietary and pharmacotherapeutrc considerations in the management of renal osteodystrophy Adv Renal Replace Ther 2:5-13,1995 9. Wilkens K, Schiro K: Suggested Gmdehnes for Nutrition Care of Renal Patients (ed 2) Chrcago, IL, American Dietenc Association, 1992, pp 19-24 10. Worthington-Roberts B, Vermeersch J: Nutrmon in Pregnancy and Lactation (ed 2). St. Lams, MO, Mosby, 1981, P 45

ESRD:

A CASE

33

STUDY

11. Pennington Portions Commonly cott, 1994, p 29

JA: Bowes and Church’s Food Values of Used (ed 16). Philadelphra, PA, Lippm-

12. Carson R, Dunmgan K, Anderson T: Efficacy efficiency hemodialysrs. JASN 1:350, 1990 (abstr) 13. Levm son between 1990 (abstr)

of high

N, Dumler F, Zasuwa G, et al: Mortality compariconventional and high flux dialysis. JASN 1:365,

14. Hormberger survival of patrents (abstr)

JC, Chernew on high flux

M, Peterson J: Improved dralysis. JASN 1:362, 1990

15. DeOreo PB: Analysis of trme, nutrition, and KT/V as risk factors for mortality in dralysis patients. JASN 2:321, 1991 (abstr) 16. Dumler F, Brickman C, Mrchaels R, et al: Differences in biocompatabrhty induced by modificatron of polysulfone membrane permeability characteristics. JASN 2:322,1991 17. Dauguus Measurement, Dial Transplant

J, Schneditz D: Postdialysrs urea rebound: prediction and effects of regional blood flow. 23:166-173, 1994

18. Kirschbaum B, Compton A, Duran M: Decreasing serum albumin levels after comersron to hrgh flux dialyses. JASN 3:374, 1992 (abstr)