Patients’ wishes, pregnancy and vascular access: When one size does not fit all

Abstract

Pregnancy in dialysis patients is a rare but important event that challenges our knowledge and demands rethinking many aspects of our practice, including vascular access. This editorial briefly discusses some open questions on vascular access in this situation that challenge the motto 'fistula first' and underline the need for personalised approaches. Information on vascular access in pregnant women is scant. Different approaches may be considered between women on dialysis already on a well-functioning tunnelled catheter and newly placed catheters: while a tunnelled catheter in a woman already stabilised on outpatient dialysis, who has shown being able to take correct care of it and who has freely chosen this option, is a reasonable choice, central venous catheters placed during pregnancy, especially in the hospital setting, may have a high risk of complications. Conversely, pregnancy may increase the risk of development of fistula aneurysms, but the frequency of this complication is still unknown. The problem of whether or not shifting pregnant patients on peritoneal dialysis to daily haemodialysis sessions is still open, as well as the role of patients' preference for avoidance of an invasive procedure, or refuse of pain. In the wait for answers, reflecting on the problems encountered by pregnant women on dialysis should make us reflect on how to improve vascular access management for all our patients.

Complex Management of Nephrotic Syndrome and Kidney Failure during Pregnancy in a Type 1 Diabetes Patient: A Challenging Case

“…While the studies by Hladunewich and coworkers, reporting previously unrecorded good outcomes in pregnancy, reassure the feasibility of intensive hemodialysis, vascular access remains a problem [ 46 , 47 ]. In particular, in our case, with the presence of profound nephrotic syndrome, the risks of catheter infection and thrombosis were considered high.…”

La grossesse en hémodialyse chronique: à propos de 25 cas survenus dans le Sud Tunisien

“…Parmi les complications obstétricales, on a recensé 2 cas d’hémorragie de la délivrance. On n’a pas noté de complications de l’abord vasculaire à type de sténose, d’anévrysme ou d’infection au niveau de la fistule artério-veineuse, bien que dans la littérature une augmentation du risque d’anévrysmes au niveau de la fistule a été rapportée [ 20 ]. La pré-éclampsie et l’hypertension sévère sont les principaux facteurs de risque de prématurité et d’autres issues indésirables.…”

Comparison of catheters or new arteriovenous fistulas for commencement of haemodialysis in pregnant women with chronic kidney disease: an international observational study

“…Vascular access choice for initiating haemodialysis in pregnancy will be informed by local practices or experiences of clinicians and patient factors including personal preferences [ 9 ]. Vascular catheters are unavoidable when urgent dialysis is required and preferred for chronic dialysis in non-pregnant patients in many centres [ 10 ].…”