Obstetric Deliveries in US Women With ESKD: 2002-2015

Abstract

Rationale & objective: Women with end-stage kidney disease (ESKD) have decreased fertility and are at increased risk for pregnancy complications. This study examined secular trends and outcomes of obstetric deliveries in a US cohort of women with ESKD.

Study design: Retrospective cohort study.

Setting & participants: Women aged 18 to 44 years with ESKD and registered in the US Renal Data System from 2002 to 2015.

Exposure: ESKD modality (hemodialysis [HD], peritoneal dialysis, transplantation).

Outcomes: Infant delivery, preterm delivery, cesarean delivery.

Analytical approach: Unadjusted delivery rates were expressed as number of delivering women per 1,000 patient-years among women aged 18 to 44 years within each year during the study period, stratified by ESKD modality. Logistic regression models were used to evaluate associations of delivery, preterm delivery, and cesarean delivery with patient characteristics.

Results: The delivery rate in women undergoing HD and women with a kidney transplant increased from 2.1 to 3.6 and 3.1 to 4.6 per 1,000 patient-years, respectively (P<0.001 for each). The delivery rate in patients undergoing peritoneal dialysis was lower and did not increase significantly (P=0.9). Women with a transplant were less likely to deliver preterm compared with women undergoing HD (OR, 0.92; 95% CI, 0.84-1.00), though more likely have a cesarean delivery (OR, 1.18; 95% CI, 1.06-1.31). For deliveries occurring in the 2012 to 2015 period, 75% of women treated with HD were prescribed 4 or fewer outpatient HD treatments per week and 25% were prescribed 5-plus treatments per week in the 30 days before delivery.

Limitations: Ascertainment of outcomes and comorbid conditions using administrative claims data.

Conclusions: The delivery rate in women of reproductive age with ESKD increased from 2002 to 2015 among those treated with transplantation or HD. Women with a functioning transplant were less likely to deliver preterm, but more likely to have a cesarean delivery. Prescriptions for outpatient intensified HD for pregnant women with ESKD were infrequent in 2012 to 2015.

Keywords: End-stage kidney disease (ESKD); KRT modality; USRDS (US Renal Data System); cesarean delivery; childbirth; delivery; fetal morbidity; hemodialysis (HD); kidney failure; kidney replacement therapy; maternal outcomes; obstetrics; peritoneal dialysis (PD); preeclampsia; pregnancy; preterm delivery; transplantation.

Figure 1.. Deliveries per 1,000 patient-years in women age 18–44 with ESKD

Unadjusted delivery rates per 1000 patient-years among women 18–44 within each year over the study period, stratified by modality.

Figure 2.. Relationships between clinical characteristics and odds of delivery

Forest plot showing multivariable association between clinical characteristics and odds of delivery (with 95% confidence intervals) using logistic generalized estimating equations accounting for multiple deliveries in a single individual and adjusted for comorbidities.

Figure 3.. Relationships between clinical characteristics and preterm delivery

Forest plot showing multivariable association between clinical characteristics and odds of preterm delivery (with 95% confidence intervals) using logistic generalized estimating equations accounting for multiple deliveries in a single individual and adjusted for comorbidities.

Figure 4.. Relationships between clinical characteristics and cesarean delivery

Forest plot showing multivariable association between clinical characteristics and odds of cesarean delivery (with 95% confidence intervals) using logistic generalized estimating equations accounting for multiple deliveries in a single individual and adjusted for comorbidities.