Dialysis and a plant-based diet to achieve physiologic urea levels for fetal benefit: Normal pregnancy outcome despite chronic kidney disease and hypertension.

Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes. A growing body of evidence suggests that intensive dialysis, achieving physiologic pre-dialysis blood urea, is associated with decreased morbidity. We report a case of a successful pregnancy outcome in a 32-year-old nulliparous woman with stage 4 chronic kidney disease who underwent haemodialysis from 11 to 31 weeks' gestation for fetal benefit and concurrently trialled a plant-based diet. We hypothesise that her dietary changes assisted with urea reduction, enabling her to become dialysis independent. Although we must recognise that such pregnancies remain high risk, as demonstrated both in this case and more recent literature, advances in complex obstetric care and dialysis protocols may now give women with chronic kidney disease a realistic hope of a successful pregnancy.

Primary Hyperparathyroidism in Pregnancy: Maternofetal Outcomes at a Quaternary Referral Obstetric Hospital, 2000 Through 2015.

Context: Primary hyperparathyroidism (PHPT) in pregnancy has historically been associated with substantial maternofetal morbidity and mortality rates. The optimal treatment and timing of surgical intervention in pregnancy remain contested. Objective: To compare maternofetal outcomes of medically and surgically treated patients with PHPT in pregnancy. Design: Retrospective chart review. Setting: Quaternary referral hospital. Patients: Women with PHPT in pregnancy treated between 1 January 2000 and 31 December 2015. Interventions: Medical therapy or parathyroid surgery. Main Outcomes Measured: Timing of diagnosis; maternal corrected serum calcium concentrations; gestation, indication and mode of delivery; complications attributable to PHPT; birth weight; and admission to the neonatal intensive care unit (NICU). Results: Twenty-two pregnancies were managed medically, and six patients underwent parathyroidectomy in pregnancy (five in trimester 2, and one at 32 weeks gestation). Most patients treated medically either had a corrected serum calcium concentration <2.85 mmol/L in early pregnancy or had PHPT diagnosed in trimester 3. Of viable medically managed pregnancies, 30% were complicated by preeclampsia, and preterm delivery occurred in 66% of this group. All preterm neonates required admission to the NICU for complications related to prematurity. All surgically treated patients delivered their babies at term, and there were no complications of parathyroid surgery. Conclusion: Maternofetal outcomes have improved relative to that reported in early medical literature in patients treated medically and surgically, but the rates of preeclampsia and preterm delivery were higher in medically treated patients. The study was limited by its retrospective design and small sample sizes.

Burden of Care and Quality of Life Among Caregivers for Adults Receiving Maintenance Dialysis: A Systematic Review.

RATIONALE & OBJECTIVE: Dialysis is a burdensome and complex treatment for which many recipients require support from caregivers. The impact of caring for people dependent on dialysis on the quality of life of the caregivers has been incompletely characterized. STUDY DESIGN: Systematic review of quantitative studies of quality of life and burden to caregivers. SETTING & STUDY POPULATION: Caregivers of adults receiving maintenance dialysis. SELECTION CRITERIA FOR STUDIES: The Cochrane Library, Embase, PsycINFO, CINAHL, PubMed, and MEDLINE were systematically searched from inception until December 2016 for quantitative studies of caregivers. Pediatric and non-English language studies were excluded. Study quality was assessed using a modified Newcastle-Ottawa scale. DATA EXTRACTION: 2 independent reviewers selected studies and extracted data using a prespecified extraction instrument. ANALYTICAL APPROACH: Descriptive reports of demographics, measurement scales, and outcomes. Quantitative meta-analysis using random effects when possible. RESULTS: 61 studies were identified that included 5,367 caregivers from 21 countries and assessed the impact on caregivers using 70 different scales. Most (85%) studies were cross-sectional. The largest identified group of caregivers was female spouses who cared for recipients of facility-based hemodialysis (72.3%) or peritoneal dialysis (20.6%). Caregiver quality of life was poorer than in the general population, mostly comparable with caregivers of people with other chronic diseases, and often better than experienced by the dialysis patients cared for. Caregiver quality of life was comparable across dialysis modalities. LIMITATIONS: Heterogeneity in study design and outcome measures made comparisons between studies difficult and precluded quantitative meta-analysis. Study quality was generally poor. CONCLUSIONS: Quality of life of caregivers of dialysis recipients is poorer than in the general population and comparable to that of caregivers of individuals with other chronic diseases. The impact of caring for recipients of home hemodialysis or changes in the impact of caring over time have not been well studied. Further research is needed to optimally inform dialysis programs how to educate and support caregivers.