Determinants of Perinatal Outcomes in Dialyzed and Transplanted Women in Australia

Erandi Hewawasam; Christopher E Davies; Zhuoyang Li; Philip Clayton; Elizabeth Sullivan; Stephen P McDonald; Shilpanjali Jesudason

doi:10.1016/j.ekir.2022.03.015

Determinants of Perinatal Outcomes in Dialyzed and Transplanted Women in Australia

Kidney Int Rep. 2022 Mar 23;7(6):1318-1331. doi: 10.1016/j.ekir.2022.03.015. eCollection 2022 Jun.

Authors

Erandi Hewawasam^{1

2}, Christopher E Davies^{1

2}, Zhuoyang Li³, Philip Clayton^{1

2

4}, Elizabeth Sullivan³, Stephen P McDonald^{1

2

4}, Shilpanjali Jesudason^{2

4}

Affiliations

¹ Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South Australia, Australia.
² Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia.
³ College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, New South Wales, Australia.
⁴ Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, South Australia, Australia.

Abstract

Introduction: Drivers of adverse perinatal outcomes in pregnancies of women receiving chronic kidney replacement therapy (KRT) remain poorly understood.

Methods: Births ≥ 20 weeks of gestation in Australian women receiving KRT were analyzed for perinatal outcomes stratified by maternal KRT exposure (dialysis or transplant, analyzed separately), by linking the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and perinatal data sets (1991-2013).

Results: Of 2,948,084 babies (1,628,181 mothers), 248 were born to mothers receiving KRT (transplant, n = 211; dialysis, n = 37), with live birth rates ≥ 94%. The perinatal death rate was 162, 62, and 9 per 1000 births in the dialysis, transplant, and non-KRT cohorts, respectively. Babies exposed to KRT had increased odds of prematurity, small-for-gestational age (SGA), poor birth condition, resuscitation, intensive care admission, and longer hospitalization, with the dialysis cohort having worse outcomes. Preterm babies of dialyzed and transplanted mothers (compared with preterm babies with no KRT exposure) experienced 1.6- to 2.7-fold higher odds for all adverse outcomes, except birthweight < 2500 g, which was 11-fold higher for the dialysis cohort. In adjusted analyses, transplanted women with better allograft function (serum creatinine ≤ 120 μmol/l) still had >10-fold higher odds of preterm birth and low birthweight and 1.8- to 4.6-fold increased odds of other adverse outcomes. In transplanted women, mediation analysis revealed that pregnancy-induced hypertension contributed only a modest proportional effect (2.5%-11.2%) on adverse outcomes.

Conclusion: Maternal dialysis and transplantation conferred excess perinatal morbidity, particularly for preterm babies, and even in women with good preconception allograft function. Pregnancy-induced hypertension is not the predominant determinant of perinatal morbidity. Preconception counseling of women with kidney disease should encompass discussion of perinatal complications.

Keywords: dialysis; fetal; kidney failure; maternal; perinatal; pregnancy; transplant.