INTRODUCTION AND AIMS: Pregnancy in advanced CKD patients is increasingly common as en effect of improvement in materno-foetal care and of deep changes in counselling. Nevertheless, the indications for dialysis start in pregnancy are neither clear nor shared. Some experts have hypothezised an indication when BUN reaches about 50 mg/dl, but no study comparing early or late dialysis start in pregnancy is available so far. As observed in the non-pregnant population, and according to previous experiences from ours and other groups, protein-restricted, supplemented, plant-based diets may promote fetal growth and stabilize kidney function and proteinuria. We would like to report on a patient in which switching to a vegan-vegetarian non-supplemented diet probably helped to avoid dialysis in pregnancy.
METHODS: A 28 years old woman with CKD known since infancy (single hypoplasic kidney with glomerulocystic disease), with stage 4 CKD, relatively stable since at least 3 years, without relevant proteinuria (0.2 g/day), and normotensive (without therapy) was first seen at the 6th gestational week of her first pregnancy; pre-pregnancy creatinine was 2.6 mg/dL.Of note, she had a very low BMI (10.3 pre pregnancy: height 155 cm, weight 40 Kg) but reported an adequate caloric intake (over 30 Kcal/Kg/day on ideal body weight). She was on a mixed-proteins moderately restricted diet, targeted at 0.6 g of mixed proteins/Kg/day (ideal weight).
RESULTS: Due to an increasing trend of urea and creatinine, the patient was prescribed the supplemented plant-based diet we usually employ in advanced CKD in pregnancy. However, she did not tolerate the supplements, and resumed her previous dietary habits. Since creatinine was increasing and urea level was reaching a "pre-dialysis" level (and the patient did not wish to start dialysis in pregnancy), she started a vegan diet (protein intake: 0.6 g/Kg/day), with a sharp decrease in urea and a milder, but relevant decrease in serum creatinine (Figure). No other change in treatment was done.During pregnancy the baby's growth was normal, with normal umbilical and uterine Doppler flow. Probably the diet contributed to prolong pregnancy without dialysis up to 33 weeks, when she was hospitalized for a new increase in serum creatinine (3.29 mg/dL) and serum urea (68 mg/dL). Labour was induced (amniorexis and oxitocine infusion) and she delivered an healthy female baby at 33 weeks and 6 days of gestational age. The baby was adequate for gestational age (weight: 1900 g, corresponding to 39th centile of Ines charts - Italian growth curves) and she was discharged after 10 days of neonatal intensive care. She continued the vegetarian diet for a few weeks after pregnancy, but then sheresumed her previous diet; after shifting to that diet, an increase of urea and creatinine was observed. Six months after delivery the mother, still on pre-dialysis care, reported wellbeing for herselfand the baby.
CONCLUSIONS: The present case may suggest that vegan-vegetarian diets may have an intrinsic advantage in pregnant CKD patients; a diet proposal may probably, at least in selected cases and under strict clinical surveillance, allow safe management of pregnancy postponing the need for dialysis start.
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