Optimized Management for Successful Pregnancy Outcomes in 3 Patients on Maintenance Hemodialysis: A Case Series with Narrative Synthesis

Optimized Management for Successful Pregnancy Outcomes in 3 Patients on Maintenance Hemodialysis: A Case Series with Narrative Synthesis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Optimized Management for Successful Pregnancy Outcomes in 3 Patients on Maintenance Hemodialysis: A Case Series with Narrative Synthesis Dan Chen, Aihong Wang, Pengfei Zhu, Lishan Tan, Wei Liang, Xiaowei Zhang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8993843/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Pregnancy success rates in women on maintenance hemodialysis (MHD) have improved, but adverse outcomes remain common. We present three cases of successful deliveries in pregnant MHD patients, supplemented by a narrative synthesis of literature to highlight key management strategies. The patients had MHD durations ranging from 2 months to 10 years. Key dialysis parameters (frequency, duration, intensity) were optimized to balance maternal hemodynamics and fetal‒placental perfusion, guided by comprehensive clinical, laboratory, and fetal monitoring. Multidisciplinary management, including strict fluid control, anemia, and thrombotic risk management, alongside tailored medication, diet, and psychological support, aimed to ensure perinatal safety. Despite efforts to prolong gestation, only one pregnancy reached full term, while the other two delivered preterm. All mothers and infants were discharged without major complications, with normal infant development and steady growth observed. Optimized MHD management during pregnancy can improve delivery outcomes and neonatal survival. This study offers a clinical reference framework for managing pregnant MHD patients. hemodialysis pregnancy nursing delivery uremia Figures Figure 1 1. Introduction Uremia is a clinical syndrome resulting from end-stage kidney dysfunction (ESKD), characterized by metabolic waste accumulation, fluid‒electrolyte imbalances, and endocrine disturbances that compromise multiple organ systems [ 1 ]. Consequently, pregnancy remains rare among uremic patients, with elevated risks of gestational complications and adverse outcomes [ 2 ]. Since 1978, only 0.9% of 13,000 uremic women of reproductive age have achieved conception [ 3 ]. The neonatal survival rate in this population is only 40.2%, with preterm delivery occurring in 83% of cases [ 4 ]. Additionally, maternal complications include preeclampsia (11.9%), hypertension (7.7%), and anemia (3.9%) [ 5 ]. These data support current recommendations for strict contraception in maintenance hemodialysis (MHD) women of childbearing age. Nevertheless, an increasing number of MHD women are now seeking successful delivery following unintended pregnancies. Optimizing clinical management during MHD treatment to improve delivery outcomes has thus emerged as a critical unmet need. Current international guidelines and expert consensus recommend therapeutic strategies—including hypertension control, intensified dialysis, and anemia correction—to mitigate pregnancy risks in MHD-treated women and reduce adverse fetal outcomes [ 6 , 7 ]. Compared with conventional hemodialysis (HD, 3 sessions/week, 4 hours/session), intensive dialysis (e.g., increased frequency or extended duration) significantly improves quality of life and long-term outcomes through enhanced toxin clearance (particularly middle/large molecules and phosphorus), more stable hemodynamics (reduced hypotension and cardiac stress), and better volume control [ 8 , 9 ]. Studies have demonstrated that intensive regimens increase 5-years survival while reducing cardiovascular complications, decreasing antihypertensive and phosphate-binder requirements, and ameliorating anemia/secondary hyperparathyroidism [ 10 , 11 ]. Intensive dialysis thus benefits patients with high quality-of-life expectations. While these measures have lowered maternal risks, they remain insufficient for improving rates of full-term deliveries. However, current knowledge is driven primarily by case experience rather than large-scale research, which precludes the development of consensus/guidelines for managing pregnant women on MHD [ 12 ]. Our HD center operates 86 HD machines. Over 400 patients receive regular HD treatment at this center. Over the past five years, three MHD women at our center have expressed a strong desire for childbirth—a scenario not previously encountered. In response, we implemented a comprehensive management protocol integrating guideline recommendations with individualized adjustments on the basis of clinical, laboratory, and fetal monitoring parameters. Rigorous surveillance and management of fluid status, anemia, and thrombotic risk were prioritized to ensure perinatal safety, complemented by tailored medication, nutritional support, and psychological care. All three patients ultimately achieved successful deliveries. This study aims to detail their end-to-end clinical management, providing evidence to further optimize pregnancy care protocols for MHD-treated women. 2. Case Presentation 2.1 Patient and medical history All three patients were on MHD and were aged 33, 30, and 34 years (Table 1 ). Patient 3 had a history of polycystic ovary syndrome. The underlying etiologies were chronic glomerulonephritis in Cases 1 and 2 and hypertensive nephropathy in Case 3. The prepregnancy dialysis durations were approximately 5 months, 10 years, and 2 months, respectively. With respect to obstetric history, Cases 1 and 2 were nulliparous, whereas Patient 3 had one previous live birth. All patients were diagnosed with pregnancy during treatment and strongly desired to continue gestation. Patients 1 and 2 received prepregnancy care at outside institutions, and baseline laboratory data were unavailable. The preconception parameters of Patient 3 included hemoglobin (98 g/L), albumin (33 g/L), creatinine (1065 µmol/L), urea (28.83 mmol/L), phosphate (2.9 mmol/L), and NT-proBNP (5424 pg/mL). Notably, these baseline data have limited reference value, as the patients' parameters fluctuate significantly due to pregnancy and kidney disease. Therefore, timely treatment adjustments on the basis of clinical experience remain crucial. No other significant complications were observed. The three patients had distinct medical histories with no prior treatment at our center until pregnancy confirmation. All histories were verbally reported with limited documentation. Patient 1 presented with proteinuria (+) and a serum creatinine level of 447.2 µmol/L during preconception screening in early 2018 and subsequently received traditional Chinese medicine. In late 2019, her creatinine exceeded 600 µmol/L following a week of febrile illness. Although dialysis was recommended, the patient deferred treatment until his creatinine level surpassed 800 µmol/L one month later. The patient was diagnosed with pregnancy after two months of dialysis. The patient reported being generally healthy with no symptoms. No kidney biopsy was performed at the time of elevated creatinine detection. Kidney ultrasound revealed mildly shrunken kidneys with indistinct corticomedullary differentiation, with the exact etiology of chronic nephritis remaining undetermined. Patient 2 was diagnosed with nephritis during school screening but continued nocturnal gaming and carbonated beverage consumption. Dialysis was initiated four months later when creatinine reached critical levels, leaving the etiology undetermined in this case. Table 1 Patient information and medical history. Case Age Disease history Primary disease MHD duration Reproductive history 1 33 N/A Chronic nephritis 5 months N/A 2 30 N/A Chronic nephritis 10 years N/A 3 34 Polycystic ovary syndrome Hypertensive nephropathy 2 months 1 child 2.2 Diagnosis All patients presented with pregnancy during MHD treatment (Table 2 ). The initial admission blood pressures were 148/94 mmHg, 98/71 mmHg, and 149/96 mmHg, with pulse rates of 81, 78, and 69 beats per minute, respectively. The gestational ages at the first hospital visit were 17 + 4 weeks, 22 weeks, and 6 + 5 weeks, with normal fetal heart rates documented in all patients. Their dry weights were 70 kg, 46.5 kg, and 71 kg, respectively, accompanied by low hemoglobin and albumin levels. The residual urine output ranged from 500–800 mL, 0 mL, to 1400–2000 mL. Vascular access comprised a central venous catheter in Patient 1 and native arteriovenous fistulae in Patients 2–3. Patients 1 and 3 used Asahi Kasei 14 L hollow-fiber dialyzers during shorter dialysis durations, whereas Patient 2's dialyzer type (treated externally) was unspecified. Patient 1 required reduced blood flow (200 mL/min) and dialysate flow (300 mL/min) due to intradialytic disequilibrium. Patient 3’s recently established arteriovenous fistulae similarly limited blood flow to 200 mL/min. All patients received thrice-weekly HD. Table 2 Laboratory parameters at pregnancy diagnosis. Case Hemoglobin (g/L) Albumin (g/L) Creatinine (umo/L) Urea (mmol/L) Phosphorus (mmol/L) NT-proBNP (pg/ml) 1 90 35.9 714 15.07 1.47 452.2 2 97 39.7 641 17.37 N/A 1689 3 111 33.5 459 20 2.01 4668 2.3 Treatment and nursing We optimized dialysis regimens by balancing maternal hemodynamic stability with fetal‒placental perfusion, incorporating comprehensive assessments of clinical presentation, laboratory parameters, and fetal monitoring data. Rigorous surveillance and management of volume status, dialysis adequacy, anemia, and thrombotic risk were implemented to ensure perinatal safety for both mothers and fetuses. This multidisciplinary approach was complemented by tailored medication protocols, nutritional guidance, and psychological support throughout the treatment course (Fig. 1 ). 2.3.1 Dry weight assessment Individualized "target weights" were established (adjusted according to gestational age) to maintain normal fluid volume while preventing both dehydration and pulmonary edema through precise fluid balance management. All three patients had a normal prepregnancy BMI and were managed according to the recommended gestational weight gain guidelines [ 13 , 14 ]: 0–2 kg during the first trimester (0–12 weeks), followed by a weekly gain of 0.37 kg (range 0.26–0.48 kg/week) in the second and third trimesters (13–40 weeks). These standards inform weekly dry weight assessments conducted by physicians. Interdialytic weight gain was strictly controlled by these parameters. Patients received standardized training for weight and blood pressure monitoring, including (i) daily fasting weight measurements. (ii) Quadruple daily blood pressure (BP) recordings (morning, noon, evening, presleep). (iii) Precise fluid intake/output tracking using graduated measuring cups. 2.3.2 Management during HD (i) Patients were assigned dedicated dialysis stations to minimize intermachine ultrafiltration variability. (ii) Continuous blood pressure, electrocardiographic, and pulse oximetry monitoring was performed, with hourly documentation of vital signs. Blood pressure deviations trigger immediate protocolized adjustments under physician supervision, including sodium profiling modulation and ultrafiltration rate titration (target intradialytic BP >120/70 mmHg, postdialytic BP <140/90 mmHg). (iii) During dialysis, treatment regimens should be adjusted on the basis of the patient's edema status, distinguishing between physiological edema (e.g., pregnancy-related) and pathological edema (e.g., volume overload) [15]. Physiological edema is characterized by weight gain within the normal range, predominantly lower limb (ankle/foot) swelling that worsens in the evening, stable blood pressure during dialysis, and no associated discomfort; in such cases, patients should adopt a left lateral position to improve venous return and elevate the lower limbs 3–4 times daily for 20 minutes each, with no need for dialysis regimen adjustment. In contrast, pathological edema presents with rapid weight gain, generalized edema accompanied by discomfort (e.g., dyspnea, hypertension), and elevated blood pressure during dialysis, necessitating modifications to the dialysis regimen, such as increasing the ultrafiltration volume, extending the duration of dialysis, or adding additional sessions. (iv) Laboratory parameters should be monitored closely. For example, hyponatremia may indicate dilutional volume overload [16], elevated urea nitrogen could reflect dehydration or hypercatabolism [17], and markedly increased NT-proBNP levels accompanied by heart failure symptoms suggest volume overload [18]. (v) Dialysis frequency should be adjusted on the basis of the patient’s clinical status. For example, Patient 1 developed dyspnea during pregnancy, prompting an increase to 4 sessions/week with an additional 500–1,000 mL ultrafiltration volume; symptoms improved, and dialysis was later reduced to 3 sessions/week. Patient 2 received 3 sessions/week before gestational week 22 and 4 sessions/week thereafter. Patient 3 was dialyzed 3 times/week until week 31, increased to 4 sessions/week at week 31, and further increased to 5 sessions/week at week 35. Both Patients 2 and 3 maintained normal weight gain without heart failure symptoms, suggesting that intensified dialysis may improve pregnancy outcomes. 2.3.3 Management of anemia Anemia compromises tissue oxygenation and repair capacity, leading to placental hypoxia and, consequently, fetal growth restriction [ 19 ]. Since erythropoietin, a large glycoprotein, does not cross the placental barrier, its use during pregnancy is considered safe [ 20 ]. Accordingly, all three patients underwent monthly hemoglobin monitoring and received erythropoietin therapy at 50–100% increased dosages, targeting hemoglobin levels of 100–110 g/L and hematocrit above 30–35% [ 6 , 13 ]. The treatment regimen consisted of weekly erythropoietin administration (10,000–20,000 IU) combined with daily folic acid supplementation (10 mg). 2.3.4 Management of thrombosis Pregnancy-induced hypercoagulability [ 21 ], compounded by postdialytic hemoconcentration, significantly elevated thrombotic risk in these patients. All three patients underwent regular monitoring of coagulation profiles, hemoglobin, and thrombotic markers, indicating that prophylactic aspirin therapy was warranted for platelet inhibition. The anticoagulant dosages were titrated on the basis of abnormal coagulation/thrombosis parameters. Patients 1 and 2 received enoxaparin sodium (Clexane®, 1000–3000 IU), while Patient 3 was administered low-molecular-weight heparin (2800 IU). Predialysis bleeding risk assessments were systematically performed, with postdialytic evaluation of circuit/clotting status informing anticoagulant adjustments, which were reduced for pristine circuits or increased for significant clot formation, as determined by the treating physician. Moreover, excessive dosing of erythropoietin can increase red blood cell production, leading to a hypercoagulable state and increasing the risk of thrombosis. In Patient 3, when hemoglobin levels exceeded 110 g/L, we reduced the erythropoietin dosage to mitigate thrombotic risk. During pregnancy, all three patients presented elevated fibrinogen (ranging from 3.72–6.49, 5.79–6.35, and 4.53–5.62 g/L, respectively) and D-dimer levels (0.36–2.07, 0.66–2.31, and 1.24 mg/L FEU, respectively) above normal ranges, whereas other coagulation parameters remained within normal limits. Notably, none of the patients developed deep vein thrombosis or experienced anemia-related ischemic/hypoxic complications. 2.3.5 Fetal monitoring To minimize the effects of hemodynamic fluctuations on fetal development, we employed small-surface-area dialyzers with superior biocompatibility [ 22 , 23 ]. The three patients utilized either the Polyflux® 14 L hollow-fiber dialyzer (Baxter International, USA) or REXEED series dialyzer (Asahi Kasei Medical, models 13LC/15LC). The treatment parameters included blood flow (200 mL/min), dialysate flow (500 mL/min), and calcium-enriched dialysate (1.5 mmol/L). The following fetal surveillance protocols were used: (i) < 28 weeks: Doppler ultrasonography during dialysis. (ii) ≥ 28 weeks: Continuous cardiotocography monitoring (fetal movement/heart rate variability). (iii) Fetal movement throughout the entire dialysis process should be monitored continuously. (iv) Supplemental monthly ultrasound was used to assess the umbilical artery resistance indices and amniotic fluid volume, with immediate obstetric consultation for abnormal findings. 2.3.6 Medication (i) Antihypertensive management is important. Patients were educated on target blood pressure ranges (120–140/70–90 mmHg) and instructed to measure BP prior to medication administration, withholding doses if the systolic BP fell below 120 mmHg. The timing of medication was adjusted on the basis of diurnal BP trends and supplemented with a low-sodium diet. The case-specific regimens included the following: Patient 1 received methyldopa combined with nifedipine, achieving blood pressure control within 150–160/90–100 mmHg. Patient 2 maintained normotensive status without requiring antihypertensive therapy. Patient 3 exhibited reverse-dipper hypertension, necessitating nighttime dose escalation of labetalol alongside standard nifedipine, which maintained her BP at 120–140/80–90 mmHg. Given the substantial risks posed by hypertension itself, nifedipine has a more favorable benefit–risk profile. Dosage requires real-time clinical adjustment on the basis of physician expertise. (ii) During fetal growth and development, the demand for calcium increases, necessitating oral calcium supplementation as prescribed by a physician. (iii) Phosphate-lowering medications should be discontinued to avoid potential teratogenic effects on the fetus. (iv) Importantly, dialysis and pregnancy can cause fluctuations in multiple physiological parameters. Physicians must therefore adjust treatment and medication regimens on the basis of real-time patient data. 2.3.7 Nutrition Each dialysis session resulted in a protein loss of 8–10 g [ 24 ], whereas concurrent fetal development imposed additional nutritional demands. Therefore, it is essential to emphasize the importance of diet to patients, prioritizing a diet rich in calories, high-quality protein, and vitamins. For general HD patients, daily protein intake should reach 1.2 g/kg/day. However, for pregnant patients on HD, dietary restrictions should be relaxed, with a recommended protein intake of 1.8 g/kg/day [ 7 ]. Additionally, patients should be advised to consume high-fiber foods to prevent constipation and should be instructed in the use of dietary tracking apps. 2.3.8 Perinatal safety assurance All three patients underwent cesarean delivery, with risks primarily involving circulatory instability, hemorrhage/thrombosis, infection, and preterm birth. For example, severe intraoperative blood pressure fluctuations can trigger cerebral hemorrhage, eclampsia, or heart failure. The risk of postoperative heart failure also increases due to increased venous return. Additionally, anticoagulant and aspirin use heightens the risk of bleeding, whereas the inherent hypercoagulable state increases the likelihood of disseminated intravascular coagulation and pulmonary embolism [ 25 , 26 ]. These risks can be mitigated through preoperative optimization of anemia and electrolytes, meticulous intraoperative volume management, and multidisciplinary postoperative monitoring—ensuring surgical intervention under optimal patient conditions. Moreover, perioperative management requires careful consideration of drug accumulation for antibiotics, anesthetics, and anticoagulants. Furthermore, a multidisciplinary team should conduct prenatal risk assessments to determine delivery strategies, medication protocols, and nursing care. Postoperatively, strict 24-hour fluid balance monitoring is essential, with close observation of circulatory status, bleeding/thrombotic events, and infection markers. Bedside continuous renal replacement therapy should be implemented via regional citrate anticoagulation to minimize the risk of bleeding. Patients may be transferred back to obstetric care upon achieving hemodynamic stability, with a gradual transition to their prepregnancy dialysis regimen following maternal recovery. 2.3.9 Psychological nursing Maternal guilt and self-blame often arise when underlying disease conditions affect fetal development. Furthermore, pregnancy failure may reduce the likelihood of future conception, exacerbating psychological distress. Consequently, enhanced psychological support throughout gestation is essential. Our standard approach includes (i) monitoring mental status and promptly addressing concerns to alleviate stress; (ii) implementing peer support to bolster confidence; (iii) teaching relaxation techniques such as controlled breathing; (iv) encouraging engagement in hobbies for distraction; (v) involving family members to provide emotional support; and (vi) vigilant postpartum monitoring for depression, given the profound physiological and psychological changes occurring after delivery. 2.4 Outcomes and follow-up Among the three patients, two delivered preterm, and one delivered at term (Tables 3 , 4 ). Table 3 reflects the metabolic disturbances in these MHD patients, as kidney impairment compromises normal metabolite clearance. Postdialysis values show marked reductions, explaining the substantial fluctuations. For reference, we have included the raw dataset in the Supplementary Information. Postoperatively, the mothers were monitored in the intensive care unit (ICU) until stabilization before transfer back to obstetric care, while all infants were admitted to the neonatal ICU. All patients and newborns were eventually discharged without complications. All three patients remained alive at follow-up. Patient 1 underwent successful kidney transplantation and no longer required dialysis, whereas patients 2 and 3 continued MHD. Eligibility for kidney transplantation was determined according to the KDIGO 2020 guidelines and assessed by Shenzhen Third People's Hospital, not our institution. All three infants demonstrated normal growth without apparent congenital abnormalities. Furthermore, the patients expressed satisfaction with their overall treatment course. Table 3 The patient's condition during pregnancy until delivery. Case Maximum amniotic fluid volume (ml) Complications during pregnancy Residual urine volume (ml) Hemoglobin (g/L) Blood albumin (g/L) Creatinine (µmo/L) Urea (mmol/L) Blood phosphorus (mmol/L) NT-proBNP (pg/ml) 1 600 Hypertension, anemia, edema, headache 1000–1500 79–90 26.9–35.9 361–865 7.63–21.7 1.11–1.86 452.2–8270 2 1600 Polyhydramnios, anemia, hypotension N/A 71–105 39.7 311–920 6.94–33.61 1.39–1.77 1101–2234 3 600 Hypertension, anemia, arrhythmia 300–500 85–112 31-33.7 459–1065 11.54–28.83 1.35–2.99 4668–33760 Table 4 Patient status during delivery. Case Gestational weeks Dry weight (kg) Neonatal status at birth Indication for delivery 1 27 + 5 75.8 Birth weight 680 g with Apgar scores of 9 at 1 minute and 10 at 5 minutes. Single umbilical artery with elevated umbilical artery resistance and fetal distress. 2 27 + 1 47.5 Birth weight 650 g with Apgar scores of 8 at 1 minute and 9 at 5 minutes. Inevitable abortion and polyhydramnios. 3 37 + 2 78 Birth weight 2650 g with Apgar scores of 9 at 1 minute and 10 at 5 minutes. Delivered at term. 3. Discussion This study reports three successful deliveries in pregnant women on MHD and synthesizes dialysis-related pregnancy management experience from 2012–2022. Optimized dialysis protocols (increased frequency to 4–5 sessions/week), strict fluid balance control, anemia correction (hemoglobin target 100–110 g/L), and thromboprophylaxis (low-dose aspirin), combined with multidisciplinary care, fetal monitoring, and individualized management, may improve outcomes. Although only one patient achieved full-term delivery, all mothers and infants were safely discharged with normal infant development. These results provide clinical evidence that systematic interventions may achieve favorable outcomes in high-risk pregnancies, although improving term delivery rates remains a key research priority. 3.1 Importance of multidisciplinary collaboration and comprehensive care The management of pregnant MHD patients requires close multidisciplinary collaboration to achieve a delicate balance between maternal stability and fetal well-being. In this study, all three patients with CKD and multiple comorbidities achieved successful deliveries through individualized dialysis regimen optimization and meticulous clinical management. These outcomes suggest that optimized management strategies may improve pregnancy outcomes in this high-risk population. Previous studies have reported successful pregnancies in MHD patients and proposed various strategies to improve outcomes, including intensified dialysis, multidisciplinary care, anemia correction, blood pressure control, fluid balance management, an unrestricted diet, and low-dose aspirin for thrombosis prevention [ 2 , 4 , 5 , 7 , 27 ]—all of which were effective in our three cases. Our study advances this field through several key innovations. First, we developed a pregnancy-specific dry weight assessment system and established weekly weight‒gain curves on the basis of China's WS/T 801–2022 standard [ 13 ], which better reflects gestational physiological changes than the fixed-weight approach reported by Yu et al. [ 28 ]. Second, we determined that hemoglobin levels exceeding 110 g/L necessitate concurrent anticoagulation regimen adjustments, thereby expanding Cabiddu et al.'s anemia-thrombosis management framework [ 6 ]. Finally, we provide the first comprehensive documentation of full-term delivery management in this population. 3.2 Challenges in full-term delivery rates Successful pregnancy in MHD patients has historically been challenging due to maternal hemodynamic instability and low fetal survival rates. However, the number of reported cases of successful deliveries has increased in recent years. Between 2012 and 2022, 22 cases were documented (supplementary Table S1 ), all involving pregnancies detected after dialysis initiation that resulted in live births. Notably, in 2016, Seker et al. reported a patient who achieved two successful pregnancies during dialysis [ 29 ]. In 2021, Medeiros et al. described a 32-year-old patient who was diagnosed with a twin pregnancy 4 months after dialysis initiation and who delivered two healthy males via cesarean section at 34 + 6 gestational weeks [ 30 ]. Only two reported cases reached full term (≥ 37 weeks), with the majority being preterm deliveries. Treatment regimens varied significantly across cases, with dialysis intensification protocols ranging from 3–7 sessions weekly (3–5 hours per session). Cesarean delivery predominated as the birth mode. Despite the increasing number of case reports, pregnancy in dialysis patients remains a rare and high-risk clinical scenario. While successful delivery is achievable, the persistent predominance of preterm births underscores the critical need to improve full-term delivery rates—a major unmet challenge in this field. 3.3 Role of dialysis intensity This study contributes to the ongoing debate regarding the relationship between dialysis duration and successful pregnancy outcomes in women on MHD. Current evidence, including meta-analyses by Piccoli et al. and cohort studies by Hladunewich et al. [ 4 , 27 ], suggests that increased dialysis frequency and duration (> 36 hours/week) correlate with higher live birth rates and improved fetal survival. Our findings both support and challenge aspects of this dose‒response relationship. In this study, Patient 3, who underwent intensified dialysis (escalating from 3–5 sessions/week, totaling ~ 20 hours/week), achieved full-term delivery—aligning with prior observations that extended dialysis improves outcomes. This finding supports the hypothesis that enhanced uremic toxin clearance and improved fluid/electrolyte balance mitigate placental insufficiency and fetal growth restriction. However, Patient 2, despite receiving 4 sessions/week (~ 16 hours/week) after gestational week 22, delivered preterm at 27 weeks, suggesting that dialysis duration alone may not guarantee term delivery. This challenges the linear dose‒response model, implying that other factors (e.g., residual kidney function, underlying etiology, or individualized dry weight management) play critical roles. Similarly, contradictory evidence exists. Li and Guo reported successful full-term deliveries with only 17.5 weekly dialysis hours (five sessions of 3.5 hours) [ 31 , 32 ], whereas Yu et al. reported preterm delivery at 34 weeks despite 28 weekly dialysis hours—the highest duration in our analysis [ 28 ]. These conflicting observations underscore the need for further investigation to determine whether a strict relationship exists between dialysis duration and term delivery probability. Notably, Patient 1 was dialyzed 3–4 times/week (12–16 hours/week) and delivered preterm, further complicating the relationship. While her dialysis duration was below the proposed "optimal" threshold, her residual urine output (500–1500 mL/day) may have partially compensated for her reduced dialysis efficacy. This underscores the need to consider residual kidney function alongside the dialysis dose, as it contributes to solute clearance and fluid homeostasis. This study highlights that while increased dialysis duration is beneficial, it is not the sole determinant of success. A multifactorial approach—integrating dialysis intensity, volume management, anemia correction, and fetal surveillance—is essential. Future research should explore whether a minimum threshold of dialysis hours exists for viable pregnancies and how patient-specific factors modulate this relationship. Our cases reinforce the value of personalized regimens over rigid adherence to generalized dialysis targets. 3.4 Potential of HD/HDF therapy The integration of HD with hemodiafiltration (HDF) represents a compelling yet underinvestigated approach for improving pregnancy outcomes in dialysis-dependent women. While our study focused on intensive HD regimens, emerging case reports suggest that combining HD with HDF may offer distinct advantages for this vulnerable population. Analysis of the 22 reported cases revealed that five patients received HDF therapy (supplementary Table S1 ). Notably, two full-term deliveries [ 31 , 32 ], along with one vaginal delivery at 36 weeks gestation [ 33 ], all employed a dialysis regimen consisting of four weekly HD sessions supplemented with one HDF session. This suggests that a 4HD+1HDF weekly protocol may increase the likelihood of term delivery. The theoretical benefits stem from the unique capacity of HDFs to remove middle-molecule toxins and inflammatory mediators through convective transport, potentially addressing two critical challenges in pregnant dialysis patients: uremic toxin accumulation and chronic inflammation. From a clinical perspective, the enhanced clearance profile of HDFs could translate into several meaningful improvements. First, its superior removal of middle-molecule toxins might reduce placental inflammation and oxidative stress, which are factors implicated in preterm birth and fetal growth restriction. Second, the improved hemodynamic stability of the modality may help maintain adequate placental perfusion during dialysis sessions, a crucial consideration given the heightened risk of intradialytic hypotension during pregnancy. Third, by more effectively clearing proinflammatory cytokines, HDFs could mitigate the systemic inflammatory state that contributes to adverse pregnancy outcomes. However, the current evidence remains limited to anecdotal reports and small case series, with significant gaps in our understanding. Critical questions persist about optimal treatment parameters, including the ideal frequency of HDF sessions, appropriate convection volumes, and potential nutrient losses that might affect fetal development. The absence of robust randomized controlled trial data leaves clinicians without clear guidance on implementing this approach in clinical practice. Moreover, the choice of dialyzer may represent another factor influencing pregnancy success. Among the seven cases reported by Xia et al. [ 34 ], four patients maintained their prepregnancy high-flux dialyzers, which is a practice that conflicts with the recommendation for small-surface-area dialyzers [ 35 ]. Whether high-flux dialyzers can improve the intrauterine environment and thereby increase pregnancy success rates requires further investigation. Future research should prioritize well-designed clinical trials comparing intensive HD alone versus combined HD/HDF regimens in pregnant dialysis patients. Such studies should evaluate not only traditional outcomes such as gestational age at delivery and birth weight but also mechanistic endpoints, including inflammatory marker profiles and placental function assessments. Additionally, research must address safety considerations specific to pregnancy, particularly regarding the potential for increased nutrient loss across the dialyzer membrane. Until more definitive evidence emerges, HDF remains an intriguing but unproven option that warrants careful consideration in the context of individualized patient care. 3.5 Risks of preterm birth, congenital anomalies, and neonatal complications An additional finding of this study suggests that, in addition to higher prematurity risks and occasional congenital anomalies, the incidence of neonatal complications may be relatively low. A retrospective analysis of 17 infants born to 16 mothers who were undergoing dialysis between 2003 and 2016 revealed that [ 36 ], compared with 51 gestational age- and sex-matched controls, these neonates had no increased risk of additional complications despite their elevated prematurity rates and certain congenital abnormalities. These findings align with the outcomes observed in the 22 cases presented in Section 3.2 . Although our study sample size was limited (n = 3), no abnormalities or complications were detected in these infants. 3.6 Fluid status and dry weight monitoring challenges The accurate assessment of fluid status and dry weight in pregnant patients undergoing MHD presents several unique clinical challenges that complicate management decisions. The physiological changes associated with pregnancy itself significantly interfere with traditional assessment methods [ 37 ], as the expected 40–50% increase in blood volume, uterine enlargement, and fetal/amniotic fluid growth make distinguishing between normal gestational weight gain and pathological fluid overload difficult. This complexity is further compounded by pregnancy-related peripheral edema [ 38 , 39 ], which may be indistinguishable from uremia- or cardiac-induced fluid retention on the basis solely of clinical examination. Current monitoring tools have important limitations in this population. While bioimpedance analysis and inferior vena cava ultrasound are valuable for assessing volume status in nonpregnant patients, their accuracy in pregnancy remains questionable due to anatomical changes and a lack of pregnancy-specific reference ranges. Biochemical markers such as NT-proBNP become less reliable as normal pregnancy elevates baseline levels, whereas hemodynamic instability during dialysis sessions—particularly the risk of intradialytic hypotension—creates additional challenges in balancing adequate fluid removal against maintaining placental perfusion [ 38 , 40 ]. The clinical decision-making process is further complicated by significant interpatient variability in residual kidney function, as demonstrated by the marked differences in our case series. Patients with preserved urine output may tolerate different fluid management approaches than anuric individuals do. Additionally, the absence of pregnancy-specific guidelines for dry weight adjustment in dialysis patients forces clinicians to rely heavily on individualized clinical judgment and multidisciplinary collaboration involving nephrologists, obstetricians, and dialysis nursing staff. Future research should focus on developing validated pregnancy-specific assessment tools and protocols to better navigate these complex clinical scenarios. 3.7 Limitations This study has several limitations. First, the assessment of volume status relies on subjective indicators such as body weight and blood pressure, and objective measures such as bioimpedance or ultrasound-derived inferior vena cava diameter are lacking. Second, the small sample size (n = 3) from a single center and the wide gestational age range introduce potential selection bias, necessitating future multicenter studies. Third, the mean follow-up period of three years for infants only allowed evaluation of short-term growth and development, leaving long-term neurocognitive outcomes uncertain. Fourth, in Patient 2, late pregnancy detection (22 weeks) delayed intervention, underscoring the need for a structured menstrual cycle monitoring system in women on dialysis. Finally, no standardized psychological assessment tools are used to evaluate or address patients' mental health status. Future research could focus on the following directions. First, intelligent volume monitoring devices (e.g., bioimpedance analyzers) could be incorporated to establish dynamic dialysis prescription models. Second, the optimal dosing for combined low-molecular-weight heparin and aspirin anticoagulation should be explored to balance bleeding and thrombotic risks. Third, multicenter cohort studies should be conducted to validate whether the "early pregnancy detection + intensified dialysis" model improves full-term delivery rates. Fourth, investigating whether a dialysis regimen of four HD sessions plus one HDF session per week enhances the likelihood of full-term births in this patient population is important. The integration of bibliographic data follows a narrative synthesis approach, drawing on case reports and cohort studies relevant to our cases. While this provides clinical context, it does not constitute a systematic review. Future work should include systematic reviews or meta-analyses to strengthen generalizability. 4. Conclusions This study demonstrated the feasibility of pregnancy in MHD patients through three successful cases, highlighting our comprehensive management approach. Key strategies include 1) optimizing maternal–fetal hemodynamics through balanced dialysis; 2) adjusting individualized regimens on the basis of multimodal monitoring; and 3) systematically managing complications (fluid balance, anemia, thrombosis) with integrated perinatal care. The analysis of published cases suggests that a combined HD/HDF regimen (4HD+1HDF weekly) may increase full-term delivery rates. While providing practical guidance for managing pregnant MHD patients, delivery timing should be determined through individualized risk‒benefit assessments that consider both maternal and fetal indicators rather than the pursuit of full-term delivery as a universal goal. Abbreviations BP, blood pressure ESKD, end-stage kidney dysfunction HD, conventional hemodialysis HDF, hemodiafiltration MHD, maintenance hemodialysis ICU, intensive care unit Declarations Author Contributions: All authors made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis and interpretation, or all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work. Funding: This work was supported by the Shenzhen Clinical Research Center for Urology and Nephrology (LCYSSQ20220823091403008), Guangdong Basic and Applied Basic Research Foundation (2023A1515111112), Shenzhen High-level Hospital Construction Fund and Peking University Shenzhen Hospital Scientific Research Fund (KYQD2024366). Institutional Review Board Statement: This study was approved by the Clinical Research Ethics Committee of Peking University Shenzhen Hospital (Case2025--013) and conducted in accordance with the ethical principles of the Declaration of Helsinki and China’s "Ethical Review Measures for Biomedical Research Involving Human Subjects." All participants provided informed consent, and anonymity and confidentiality were ensured. All participants provided broad informed consent for noncommercial research use of their data. As a retrospective analysis, the ethics committee granted an exemption from written informed consent. No personally identifiable information was used, and the study posed no additional risks to the participants. Informed Consent Statement: Written informed consent was obtained from all the subjects involved in the study. The patients provided written informed consent for the publication of their personal or clinical information, including any identifiable images, in this study. Data Availability Statement: The raw data are available from the corresponding author upon request. Acknowledgments: We are grateful to all our colleagues in the clinical departments and laboratories. We thank Shenzhen OpenScience Technology Co., Ltd. for their assistance in polishing this languge. Conflicts of Interest: The authors declare no conflicts of interest. References Liao Y, Wang A, Sui W, Khan A, Xiong Z, Yang G. Involuntary Falls in Patients with Chronic Kidney Diseases on Nephrology Wards: Research Advances and Future Perspectives. Nursing: Res Reviews. 2024;14:1–12. Hladunewich M, Schatell D. Intensive dialysis and pregnancy. Hemodial Int. 2016;20(3):339–48. Thompson S, Marnoch CA, Habib S, Robinson H, Pauly RP. A successful term pregnancy using in-center intensive quotidian hemodialysis. Hemodial Int. 2011;15(Suppl 1):S59–63. Piccoli GB, Minelli F, Versino E, Cabiddu G, Attini R, Vigotti FN, Rolfo A, Giuffrida D, Colombi N, Pani A, Todros T. Pregnancy in dialysis patients in the new millennium: a systematic review and meta-regression analysis correlating dialysis schedules and pregnancy outcomes. Nephrol Dial Transpl. 2016;31(11):1915–34. Baouche H, Jais JP, Meriem S, Kareche M, Moranne O, Vigneau C, Couchoud C. Pregnancy in women on chronic dialysis in the last decade (2010–2020): a systematic review. Clin Kidney J. 2023;16(1):138–50. Cabiddu G, Castellino S, Gernone G, Santoro D, Giacchino F, Credendino O, Daidone G, Gregorini G, Moroni G, Attini R, et al. Best practices on pregnancy on dialysis: the Italian Study Group on Kidney and Pregnancy. J Nephrol. 2015;28(3):279–88. Wiles K, Chappell L, Clark K, Elman L, Hall M, Lightstone L, Mohamed G, Mukherjee D, Nelson-Piercy C, Webster P, et al. Clinical practice guideline on pregnancy and renal disease. BMC Nephrol. 2019;20(1):401. Wald R, Perl J. Extended hours hemodialysis and survival: extended hours, extended evidence? Kidney Int. 2016;90(6):1155–7. Nesrallah GE, Lindsay RM, Cuerden MS, Garg AX, Port F, Austin PC, Moist LM, Pierratos A, Chan CT, Zimmerman D, et al. Intensive hemodialysis associates with improved survival compared with conventional hemodialysis. J Am Soc Nephrol. 2012;23(4):696–705. Chertow GM, Levin NW, Beck GJ, Depner TA, Eggers PW, Gassman JJ, Gorodetskaya I, Greene T, James S, Larive B, et al. In-center hemodialysis six times per week versus three times per week. N Engl J Med. 2010;363(24):2287–300. Culleton BF, Walsh M, Klarenbach SW, Mortis G, Scott-Douglas N, Quinn RR, Tonelli M, Donnelly S, Friedrich MG, Kumar A, et al. Effect of frequent nocturnal hemodialysis vs conventional hemodialysis on left ventricular mass and quality of life: a randomized controlled trial. JAMA. 2007;298(11):1291–9. Copur S, Berkkan M, Basile C, Cozzolino M, Kanbay M. Dialysis in Pregnancy: An Update Review. Blood Purif. 2023;52(7–8):686–93. Guidelines for Recommended. Weight Gain During Pregnancy (WST801-2022); 2022. Dalfra MG, Burlina S, Lapolla A. Weight gain during pregnancy: A narrative review on the recent evidences. Diabetes Res Clin Pract. 2022;188:109913. Lent-Schochet D, Jialal I. Physiology, Edema. In: StatPearls. edn. Treasure Island (FL): StatPearls Publishing Copyright © 2025, StatPearls Publishing LLC.; 2025. Sahay M, Sahay R. Hyponatremia: A practical approach. Indian J Endocrinol Metab. 2014;18(6):760–71. Lacey J, Corbett J, Forni L, Hooper L, Hughes F, Minto G, Moss C, Price S, Whyte G, Woodcock T, et al. A multidisciplinary consensus on dehydration: definitions, diagnostic methods and clinical implications. Ann Med. 2019;51(3–4):232–51. Panagopoulou V, Deftereos S, Kossyvakis C, Raisakis K, Giannopoulos G, Bouras G, Pyrgakis V, Cleman MW. NTproBNP: an important biomarker in cardiac diseases. Curr Top Med Chem. 2013;13(2):82–94. Shi H, Chen L, Wang Y, Sun M, Guo Y, Ma S, Wang X, Jiang H, Wang X, Lu J, et al. Severity of Anemia During Pregnancy and Adverse Maternal and Fetal Outcomes. JAMA Netw Open. 2022;5(2):e2147046. Zanjani ED, Pixley JS, Slotnick N, MacKintosh FR, Ekhterae D, Clemons G. Erythropoietin does not cross the placenta into the fetus. Pathobiology. 1993;61(3–4):211–5. James AH. Pregnancy and thrombotic risk. Crit Care Med. 2010;38(2 Suppl):S57–63. Vázquez-Rodríguez JG. Hemodialysis and pregnancy: technical aspects. Cir Cir. 2010;78(1):99–102. Manisco G, Potì M, Maggiulli G, Di Tullio M, Losappio V, Vernaglione L. Pregnancy in end-stage renal disease patients on dialysis: how to achieve a successful delivery. Clin Kidney J. 2015;8(3):293–9. Hendriks FK, Smeets JSJ, Broers NJH, van Kranenburg JMX, van der Sande FM, Kooman JP, van Loon LJC. End-Stage Renal Disease Patients Lose a Substantial Amount of Amino Acids during Hemodialysis. J Nutr. 2020;150(5):1160–6. Ren H, Liang W, Wang A, Xiong Z, Yang G. Low Molecular Weight Heparin-Induced Thrombocytopenia: A Case Series Study of Newly Admitted Hemodialysis Patients. Hemodial Int 2025. Shah IK, Merfeld JM, Chun J, Tak T. Pathophysiology and Management of Pulmonary Embolism. Int J Angiol. 2022;31(3):143–9. Hladunewich MA, Hou S, Odutayo A, Cornelis T, Pierratos A, Goldstein M, Tennankore K, Keunen J, Hui D, Chan CT. Intensive hemodialysis associates with improved pregnancy outcomes: a Canadian and United States cohort comparison. J Am Soc Nephrol. 2014;25(5):1103–9. Yu P, Diao W, Tang Q, Jiang X. A successful pregnancy and parturition in a patient with anuria undergoing maintenance hemodialysis for 6 years: a case report of a 3-year-follow-up. BMC Pregnancy Childbirth. 2015;15:218. Seker A. Two successive pregnancies in a patient during 14 years of hemodialysis: a case report. J Med Case Rep. 2016;10:50. Medeiros R, Pais MSJ, Freitas L, Moura P. [Pregnancy and Hemodialysis: About a Successful Twin Pregnancy]. Acta Med Port. 2021;34(1):56–8. Li H, Zhao Y, Zhu Y, Tong Z, Sun Y. Breaking the Barrier: Achieving Term Delivery Following 11 Years of Hemodialysis - A Clinically Significant Case (Chinese Edition). J Chin Physician. 2018;20(2):305–6. Guo L, Xu J, Gao X, Sun Y, Pu L. Nursing Management of Pregnancy in a Uremic Patient Receiving Maintenance Hemodialysis: A Case Study (Chinese Edition). Chin J Nurs. 2018;53(6):756–8. Li Y. Spontaneous Delivery in a Maintenance Hemodialysis Patient: A Case Report​ (Chinese Edition). Henan Med Res. 2019;28(15):2879–80. Xia Q, Zhang P, Sheng K, Ren P, Song Y, Zhai L, Chen J. Pregnancy Outcomes in Maintenance Hemodialysis: Institutional Experience (7 Cases) and Meta-Analysis of 169 Published Cases (Chinese Edition). Chin J Nephrol. 2018;34(10):759–64. Reddy SS, Holley JL. Management of the pregnant chronic dialysis patient. Adv Chronic Kidney Dis. 2007;14(2):146–55. Imai K, Wada M, Ogawa M, Tsuchiya K, Kusuda S. Neonatal Outcomes of Infants Born to Women on Hemodialysis: A Single-Center, Case-Control Study. Am J Perinatol. 2023;40(7):741–7. Soma-Pillay P, Nelson-Piercy C, Tolppanen H, Mebazaa A. Physiological changes in pregnancy. Cardiovasc J Afr. 2016;27(2):89–94. Khraibi AA. Renal interstitial hydrostatic pressure and sodium excretion in hypertension and pregnancy. J Hypertens Suppl. 2002;20(3):S21–27. Davison JM. Edema in pregnancy. Kidney Int Suppl. 1997;59:S90–96. Minhas AS, Rooney MR, Fang M, Zhang S, Ndumele CE, Tang O, Schulman SP, Michos ED, McEvoy JW, Echouffo-Tcheugui J et al. Prevalence and Correlates of Elevated NT-proBNP in Pregnant Women in the General U.S. Population. JACC Adv 2023, 2(2). Additional Declarations No competing interests reported. Supplementary Files supplementarytables1.docx Supplementary Materials: Table S1 in the supplementary materials. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8993843","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":611632012,"identity":"730cf46e-a249-47f7-99df-e6d105ed7e07","order_by":0,"name":"Dan Chen","email":"","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Chen","suffix":""},{"id":611632021,"identity":"cb0652ec-88f1-4629-90c6-e445052841d9","order_by":1,"name":"Aihong Wang","email":"","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":false,"prefix":"","firstName":"Aihong","middleName":"","lastName":"Wang","suffix":""},{"id":611632030,"identity":"e8eeb626-8cf8-4f04-b1bc-f0a92985e72e","order_by":2,"name":"Pengfei Zhu","email":"","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":false,"prefix":"","firstName":"Pengfei","middleName":"","lastName":"Zhu","suffix":""},{"id":611632042,"identity":"4f5dc71a-ff2e-4def-be2a-c26af68179c8","order_by":3,"name":"Lishan Tan","email":"","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":false,"prefix":"","firstName":"Lishan","middleName":"","lastName":"Tan","suffix":""},{"id":611632044,"identity":"b36bd035-9166-4a41-9110-437ff2e34d8f","order_by":4,"name":"Wei Liang","email":"","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Liang","suffix":""},{"id":611632047,"identity":"8cdd530f-6534-470e-97f9-77ce046ad079","order_by":5,"name":"Xiaowei Zhang","email":"","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":false,"prefix":"","firstName":"Xiaowei","middleName":"","lastName":"Zhang","suffix":""},{"id":611632049,"identity":"9c145772-4f6f-418a-8791-6853c96282d6","order_by":6,"name":"Dibin Wu","email":"","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":false,"prefix":"","firstName":"Dibin","middleName":"","lastName":"Wu","suffix":""},{"id":611632050,"identity":"faf99ff9-6a4b-44e8-a19e-ba4de05b466f","order_by":7,"name":"Zibo Xiong","email":"","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":false,"prefix":"","firstName":"Zibo","middleName":"","lastName":"Xiong","suffix":""},{"id":611632058,"identity":"e00f7cb6-98d0-4656-80e9-7ea264154327","order_by":8,"name":"Guang Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYFACNiA+wCDH3gDiGFgQr8WY5wBYiwTxWhJ7wFoYiNBicPxY4oMfZ+zSe9h7TDf8KJBg4G/vTsCv5UzaYcOeG8m5PTzH0m72AB0mcebsBvxaDqS3SfB8YM7dL5F87AYPUIuBRC4BLeeft0n++VCfziOR2HbzD1FabqQdk+a5cTiBB2jLbaJskbzxLNlY5sxxQ5BfbssYSPAQ9Avf+TTDh2+OVcvzsPeY3Xzzx0aOv70XvxaFA2gCPHiVg4B8A0Elo2AUjIJRMOIBAJB+Su2F83NvAAAAAElFTkSuQmCC","orcid":"","institution":"Shenzhen Hospital Peking University, Peking University","correspondingAuthor":true,"prefix":"","firstName":"Guang","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-02-28 09:24:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8993843/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8993843/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105366714,"identity":"6c578197-bafd-4189-b7ac-aa78f158d34e","added_by":"auto","created_at":"2026-03-25 08:44:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":486713,"visible":true,"origin":"","legend":"\u003cp\u003eA comprehensive clinical care protocol was implemented to maintain all maternal physiological parameters within normal ranges, with detailed management strategies described in the main text. BP, blood pressure. MDT, multidisciplinary treatment. All the figures were created by the authors and do not involve copyright issues.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8993843/v1/48cf80f316e3bfc8888538a0.png"},{"id":108671437,"identity":"032ad061-e7c5-427e-b77c-fa08faf41667","added_by":"auto","created_at":"2026-05-07 07:42:51","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":700644,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8993843/v1/3a6184f2-3632-4999-a072-9450edf0bef4.pdf"},{"id":105366715,"identity":"663bd1a3-b6ae-4c63-aaac-7349750b60f8","added_by":"auto","created_at":"2026-03-25 08:44:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":62683,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSupplementary Materials:\u0026nbsp;\u003c/strong\u003eTable S1 in the supplementary materials.\u003c/p\u003e","description":"","filename":"supplementarytables1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8993843/v1/999ad90353904a01030669b0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Optimized Management for Successful Pregnancy Outcomes in 3 Patients on Maintenance Hemodialysis: A Case Series with Narrative Synthesis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eUremia is a clinical syndrome resulting from end-stage kidney dysfunction (ESKD), characterized by metabolic waste accumulation, fluid‒electrolyte imbalances, and endocrine disturbances that compromise multiple organ systems [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Consequently, pregnancy remains rare among uremic patients, with elevated risks of gestational complications and adverse outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Since 1978, only 0.9% of 13,000 uremic women of reproductive age have achieved conception [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The neonatal survival rate in this population is only 40.2%, with preterm delivery occurring in 83% of cases [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Additionally, maternal complications include preeclampsia (11.9%), hypertension (7.7%), and anemia (3.9%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These data support current recommendations for strict contraception in maintenance hemodialysis (MHD) women of childbearing age. Nevertheless, an increasing number of MHD women are now seeking successful delivery following unintended pregnancies. Optimizing clinical management during MHD treatment to improve delivery outcomes has thus emerged as a critical unmet need.\u003c/p\u003e\u003cp\u003eCurrent international guidelines and expert consensus recommend therapeutic strategies\u0026mdash;including hypertension control, intensified dialysis, and anemia correction\u0026mdash;to mitigate pregnancy risks in MHD-treated women and reduce adverse fetal outcomes [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Compared with conventional hemodialysis (HD, 3 sessions/week, 4 hours/session), intensive dialysis (e.g., increased frequency or extended duration) significantly improves quality of life and long-term outcomes through enhanced toxin clearance (particularly middle/large molecules and phosphorus), more stable hemodynamics (reduced hypotension and cardiac stress), and better volume control [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Studies have demonstrated that intensive regimens increase 5-years survival while reducing cardiovascular complications, decreasing antihypertensive and phosphate-binder requirements, and ameliorating anemia/secondary hyperparathyroidism [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Intensive dialysis thus benefits patients with high quality-of-life expectations. While these measures have lowered maternal risks, they remain insufficient for improving rates of full-term deliveries. However, current knowledge is driven primarily by case experience rather than large-scale research, which precludes the development of consensus/guidelines for managing pregnant women on MHD [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur HD center operates 86 HD machines. Over 400 patients receive regular HD treatment at this center. Over the past five years, three MHD women at our center have expressed a strong desire for childbirth\u0026mdash;a scenario not previously encountered. In response, we implemented a comprehensive management protocol integrating guideline recommendations with individualized adjustments on the basis of clinical, laboratory, and fetal monitoring parameters. Rigorous surveillance and management of fluid status, anemia, and thrombotic risk were prioritized to ensure perinatal safety, complemented by tailored medication, nutritional support, and psychological care. All three patients ultimately achieved successful deliveries. This study aims to detail their end-to-end clinical management, providing evidence to further optimize pregnancy care protocols for MHD-treated women.\u003c/p\u003e"},{"header":"2. Case Presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patient and medical history\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAll three patients were on MHD and were aged 33, 30, and 34 years (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Patient 3 had a history of polycystic ovary syndrome. The underlying etiologies were chronic glomerulonephritis in Cases 1 and 2 and hypertensive nephropathy in Case 3. The prepregnancy dialysis durations were approximately 5 months, 10 years, and 2 months, respectively. With respect to obstetric history, Cases 1 and 2 were nulliparous, whereas Patient 3 had one previous live birth. All patients were diagnosed with pregnancy during treatment and strongly desired to continue gestation. Patients 1 and 2 received prepregnancy care at outside institutions, and baseline laboratory data were unavailable. The preconception parameters of Patient 3 included hemoglobin (98 g/L), albumin (33 g/L), creatinine (1065 \u0026micro;mol/L), urea (28.83 mmol/L), phosphate (2.9 mmol/L), and NT-proBNP (5424 pg/mL). Notably, these baseline data have limited reference value, as the patients' parameters fluctuate significantly due to pregnancy and kidney disease. Therefore, timely treatment adjustments on the basis of clinical experience remain crucial. No other significant complications were observed.\u003c/p\u003e \u003cp\u003eThe three patients had distinct medical histories with no prior treatment at our center until pregnancy confirmation. All histories were verbally reported with limited documentation. Patient 1 presented with proteinuria (+) and a serum creatinine level of 447.2 \u0026micro;mol/L during preconception screening in early 2018 and subsequently received traditional Chinese medicine. In late 2019, her creatinine exceeded 600 \u0026micro;mol/L following a week of febrile illness. Although dialysis was recommended, the patient deferred treatment until his creatinine level surpassed 800 \u0026micro;mol/L one month later. The patient was diagnosed with pregnancy after two months of dialysis. The patient reported being generally healthy with no symptoms. No kidney biopsy was performed at the time of elevated creatinine detection. Kidney ultrasound revealed mildly shrunken kidneys with indistinct corticomedullary differentiation, with the exact etiology of chronic nephritis remaining undetermined. Patient 2 was diagnosed with nephritis during school screening but continued nocturnal gaming and carbonated beverage consumption. Dialysis was initiated four months later when creatinine reached critical levels, leaving the etiology undetermined in this case.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient information and medical history.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDisease history\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimary disease\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMHD duration\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eReproductive history\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic nephritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChronic nephritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePolycystic ovary syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHypertensive nephropathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 child\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Diagnosis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAll patients presented with pregnancy during MHD treatment (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The initial admission blood pressures were 148/94 mmHg, 98/71 mmHg, and 149/96 mmHg, with pulse rates of 81, 78, and 69 beats per minute, respectively. The gestational ages at the first hospital visit were 17\u0026thinsp;+\u0026thinsp;4 weeks, 22 weeks, and 6\u0026thinsp;+\u0026thinsp;5 weeks, with normal fetal heart rates documented in all patients. Their dry weights were 70 kg, 46.5 kg, and 71 kg, respectively, accompanied by low hemoglobin and albumin levels. The residual urine output ranged from 500\u0026ndash;800 mL, 0 mL, to 1400\u0026ndash;2000 mL. Vascular access comprised a central venous catheter in Patient 1 and native arteriovenous fistulae in Patients 2\u0026ndash;3. Patients 1 and 3 used Asahi Kasei 14 L hollow-fiber dialyzers during shorter dialysis durations, whereas Patient 2's dialyzer type (treated externally) was unspecified. Patient 1 required reduced blood flow (200 mL/min) and dialysate flow (300 mL/min) due to intradialytic disequilibrium. Patient 3\u0026rsquo;s recently established arteriovenous fistulae similarly limited blood flow to 200 mL/min. All patients received thrice-weekly HD.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLaboratory parameters at pregnancy diagnosis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHemoglobin (g/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlbumin (g/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCreatinine (umo/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUrea (mmol/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePhosphorus (mmol/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNT-proBNP (pg/ml)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e714\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e452.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e641\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1689\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e459\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Treatment and nursing\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWe optimized dialysis regimens by balancing maternal hemodynamic stability with fetal‒placental perfusion, incorporating comprehensive assessments of clinical presentation, laboratory parameters, and fetal monitoring data. Rigorous surveillance and management of volume status, dialysis adequacy, anemia, and thrombotic risk were implemented to ensure perinatal safety for both mothers and fetuses. This multidisciplinary approach was complemented by tailored medication protocols, nutritional guidance, and psychological support throughout the treatment course (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Dry weight assessment\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIndividualized \"target weights\" were established (adjusted according to gestational age) to maintain normal fluid volume while preventing both dehydration and pulmonary edema through precise fluid balance management. All three patients had a normal prepregnancy BMI and were managed according to the recommended gestational weight gain guidelines [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]: 0\u0026ndash;2 kg during the first trimester (0\u0026ndash;12 weeks), followed by a weekly gain of 0.37 kg (range 0.26\u0026ndash;0.48 kg/week) in the second and third trimesters (13\u0026ndash;40 weeks). These standards inform weekly dry weight assessments conducted by physicians. Interdialytic weight gain was strictly controlled by these parameters. Patients received standardized training for weight and blood pressure monitoring, including (i) daily fasting weight measurements. (ii) Quadruple daily blood pressure (BP) recordings (morning, noon, evening, presleep). (iii) Precise fluid intake/output tracking using graduated measuring cups.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Management during HD\u003c/h2\u003e\u003cp\u003e(i) Patients were assigned dedicated dialysis stations to minimize intermachine ultrafiltration variability. (ii) Continuous blood pressure, electrocardiographic, and pulse oximetry monitoring was performed, with hourly documentation of vital signs. Blood pressure deviations trigger immediate protocolized adjustments under physician supervision, including sodium profiling modulation and ultrafiltration rate titration (target intradialytic BP \u0026gt;120/70 mmHg, postdialytic BP \u0026lt;140/90 mmHg).\u003c/p\u003e\n\u003cp\u003e(iii) During dialysis, treatment regimens should be adjusted on the basis of the patient\u0026apos;s edema status, distinguishing between physiological edema (e.g., pregnancy-related) and pathological edema (e.g., volume overload) [15]. Physiological edema is characterized by weight gain within the normal range, predominantly lower limb (ankle/foot) swelling that worsens in the evening, stable blood pressure during dialysis, and no associated discomfort; in such cases, patients should adopt a left lateral position to improve venous return and elevate the lower limbs 3\u0026ndash;4 times daily for 20 minutes each, with no need for dialysis regimen adjustment. In contrast, pathological edema presents with rapid weight gain, generalized edema accompanied by discomfort (e.g., dyspnea, hypertension), and elevated blood pressure during dialysis, necessitating modifications to the dialysis regimen, such as increasing the ultrafiltration volume, extending the duration of dialysis, or adding additional sessions.\u003c/p\u003e\n\u003cp\u003e(iv) Laboratory parameters should be monitored closely. For example, hyponatremia may indicate dilutional volume overload [16], elevated urea nitrogen could reflect dehydration or hypercatabolism [17], and markedly increased NT-proBNP levels accompanied by heart failure symptoms suggest volume overload [18]. (v) Dialysis frequency should be adjusted on the basis of the patient\u0026rsquo;s clinical status. For example, Patient 1 developed dyspnea during pregnancy, prompting an increase to 4 sessions/week with an additional 500\u0026ndash;1,000 mL ultrafiltration volume; symptoms improved, and dialysis was later reduced to 3 sessions/week. Patient 2 received 3 sessions/week before gestational week 22 and 4 sessions/week thereafter. Patient 3 was dialyzed 3 times/week until week 31, increased to 4 sessions/week at week 31, and further increased to 5 sessions/week at week 35. Both Patients 2 and 3 maintained normal weight gain without heart failure symptoms, suggesting that intensified dialysis may improve pregnancy outcomes.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.3 Management of anemia\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAnemia compromises tissue oxygenation and repair capacity, leading to placental hypoxia and, consequently, fetal growth restriction [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Since erythropoietin, a large glycoprotein, does not cross the placental barrier, its use during pregnancy is considered safe [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Accordingly, all three patients underwent monthly hemoglobin monitoring and received erythropoietin therapy at 50\u0026ndash;100% increased dosages, targeting hemoglobin levels of 100\u0026ndash;110 g/L and hematocrit above 30\u0026ndash;35% [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The treatment regimen consisted of weekly erythropoietin administration (10,000\u0026ndash;20,000 IU) combined with daily folic acid supplementation (10 mg).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.3.4 Management of thrombosis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003ePregnancy-induced hypercoagulability [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], compounded by postdialytic hemoconcentration, significantly elevated thrombotic risk in these patients. All three patients underwent regular monitoring of coagulation profiles, hemoglobin, and thrombotic markers, indicating that prophylactic aspirin therapy was warranted for platelet inhibition. The anticoagulant dosages were titrated on the basis of abnormal coagulation/thrombosis parameters. Patients 1 and 2 received enoxaparin sodium (Clexane\u0026reg;, 1000\u0026ndash;3000 IU), while Patient 3 was administered low-molecular-weight heparin (2800 IU). Predialysis bleeding risk assessments were systematically performed, with postdialytic evaluation of circuit/clotting status informing anticoagulant adjustments, which were reduced for pristine circuits or increased for significant clot formation, as determined by the treating physician. Moreover, excessive dosing of erythropoietin can increase red blood cell production, leading to a hypercoagulable state and increasing the risk of thrombosis. In Patient 3, when hemoglobin levels exceeded 110 g/L, we reduced the erythropoietin dosage to mitigate thrombotic risk.\u003c/p\u003e \u003cp\u003eDuring pregnancy, all three patients presented elevated fibrinogen (ranging from 3.72\u0026ndash;6.49, 5.79\u0026ndash;6.35, and 4.53\u0026ndash;5.62 g/L, respectively) and D-dimer levels (0.36\u0026ndash;2.07, 0.66\u0026ndash;2.31, and 1.24 mg/L FEU, respectively) above normal ranges, whereas other coagulation parameters remained within normal limits. Notably, none of the patients developed deep vein thrombosis or experienced anemia-related ischemic/hypoxic complications.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.3.5 Fetal monitoring\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTo minimize the effects of hemodynamic fluctuations on fetal development, we employed small-surface-area dialyzers with superior biocompatibility [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The three patients utilized either the Polyflux\u0026reg; 14 L hollow-fiber dialyzer (Baxter International, USA) or REXEED series dialyzer (Asahi Kasei Medical, models 13LC/15LC). The treatment parameters included blood flow (200 mL/min), dialysate flow (500 mL/min), and calcium-enriched dialysate (1.5 mmol/L). The following fetal surveillance protocols were used: (i)\u0026thinsp;\u0026lt;\u0026thinsp;28 weeks: Doppler ultrasonography during dialysis. (ii)\u0026thinsp;\u0026ge;\u0026thinsp;28 weeks: Continuous cardiotocography monitoring (fetal movement/heart rate variability). (iii) Fetal movement throughout the entire dialysis process should be monitored continuously. (iv) Supplemental monthly ultrasound was used to assess the umbilical artery resistance indices and amniotic fluid volume, with immediate obstetric consultation for abnormal findings.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003e2.3.6 Medication\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e(i) Antihypertensive management is important. Patients were educated on target blood pressure ranges (120\u0026ndash;140/70\u0026ndash;90 mmHg) and instructed to measure BP prior to medication administration, withholding doses if the systolic BP fell below 120 mmHg. The timing of medication was adjusted on the basis of diurnal BP trends and supplemented with a low-sodium diet. The case-specific regimens included the following: Patient 1 received methyldopa combined with nifedipine, achieving blood pressure control within 150\u0026ndash;160/90\u0026ndash;100 mmHg. Patient 2 maintained normotensive status without requiring antihypertensive therapy. Patient 3 exhibited reverse-dipper hypertension, necessitating nighttime dose escalation of labetalol alongside standard nifedipine, which maintained her BP at 120\u0026ndash;140/80\u0026ndash;90 mmHg. Given the substantial risks posed by hypertension itself, nifedipine has a more favorable benefit\u0026ndash;risk profile. Dosage requires real-time clinical adjustment on the basis of physician expertise. (ii) During fetal growth and development, the demand for calcium increases, necessitating oral calcium supplementation as prescribed by a physician. (iii) Phosphate-lowering medications should be discontinued to avoid potential teratogenic effects on the fetus. (iv) Importantly, dialysis and pregnancy can cause fluctuations in multiple physiological parameters. Physicians must therefore adjust treatment and medication regimens on the basis of real-time patient data.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.3.7 Nutrition\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eEach dialysis session resulted in a protein loss of 8\u0026ndash;10 g [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], whereas concurrent fetal development imposed additional nutritional demands. Therefore, it is essential to emphasize the importance of diet to patients, prioritizing a diet rich in calories, high-quality protein, and vitamins. For general HD patients, daily protein intake should reach 1.2 g/kg/day. However, for pregnant patients on HD, dietary restrictions should be relaxed, with a recommended protein intake of 1.8 g/kg/day [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, patients should be advised to consume high-fiber foods to prevent constipation and should be instructed in the use of dietary tracking apps.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.3.8 Perinatal safety assurance\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAll three patients underwent cesarean delivery, with risks primarily involving circulatory instability, hemorrhage/thrombosis, infection, and preterm birth. For example, severe intraoperative blood pressure fluctuations can trigger cerebral hemorrhage, eclampsia, or heart failure. The risk of postoperative heart failure also increases due to increased venous return. Additionally, anticoagulant and aspirin use heightens the risk of bleeding, whereas the inherent hypercoagulable state increases the likelihood of disseminated intravascular coagulation and pulmonary embolism [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. These risks can be mitigated through preoperative optimization of anemia and electrolytes, meticulous intraoperative volume management, and multidisciplinary postoperative monitoring\u0026mdash;ensuring surgical intervention under optimal patient conditions.\u003c/p\u003e \u003cp\u003eMoreover, perioperative management requires careful consideration of drug accumulation for antibiotics, anesthetics, and anticoagulants. Furthermore, a multidisciplinary team should conduct prenatal risk assessments to determine delivery strategies, medication protocols, and nursing care. Postoperatively, strict 24-hour fluid balance monitoring is essential, with close observation of circulatory status, bleeding/thrombotic events, and infection markers. Bedside continuous renal replacement therapy should be implemented via regional citrate anticoagulation to minimize the risk of bleeding. Patients may be transferred back to obstetric care upon achieving hemodynamic stability, with a gradual transition to their prepregnancy dialysis regimen following maternal recovery.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.3.9 Psychological nursing\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eMaternal guilt and self-blame often arise when underlying disease conditions affect fetal development. Furthermore, pregnancy failure may reduce the likelihood of future conception, exacerbating psychological distress. Consequently, enhanced psychological support throughout gestation is essential. Our standard approach includes (i) monitoring mental status and promptly addressing concerns to alleviate stress; (ii) implementing peer support to bolster confidence; (iii) teaching relaxation techniques such as controlled breathing; (iv) encouraging engagement in hobbies for distraction; (v) involving family members to provide emotional support; and (vi) vigilant postpartum monitoring for depression, given the profound physiological and psychological changes occurring after delivery.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Outcomes and follow-up\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAmong the three patients, two delivered preterm, and one delivered at term (Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e reflects the metabolic disturbances in these MHD patients, as kidney impairment compromises normal metabolite clearance. Postdialysis values show marked reductions, explaining the substantial fluctuations. For reference, we have included the raw dataset in the Supplementary Information. Postoperatively, the mothers were monitored in the intensive care unit (ICU) until stabilization before transfer back to obstetric care, while all infants were admitted to the neonatal ICU. All patients and newborns were eventually discharged without complications.\u003c/p\u003e\u003cp\u003eAll three patients remained alive at follow-up. Patient 1 underwent successful kidney transplantation and no longer required dialysis, whereas patients 2 and 3 continued MHD. Eligibility for kidney transplantation was determined according to the KDIGO 2020 guidelines and assessed by Shenzhen Third People's Hospital, not our institution. All three infants demonstrated normal growth without apparent congenital abnormalities. Furthermore, the patients expressed satisfaction with their overall treatment course.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe patient's condition during pregnancy until delivery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaximum amniotic fluid volume (ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eComplications during pregnancy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResidual urine volume (ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHemoglobin (g/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlood albumin (g/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCreatinine (\u0026micro;mo/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eUrea (mmol/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eBlood phosphorus (mmol/L)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNT-proBNP (pg/ml)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHypertension, anemia, edema, headache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1000\u0026ndash;1500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79\u0026ndash;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26.9\u0026ndash;35.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e361\u0026ndash;865\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7.63\u0026ndash;21.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.11\u0026ndash;1.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e452.2\u0026ndash;8270\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePolyhydramnios, anemia, hypotension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71\u0026ndash;105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e39.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e311\u0026ndash;920\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e6.94\u0026ndash;33.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.39\u0026ndash;1.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1101\u0026ndash;2234\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e600\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHypertension, anemia, arrhythmia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e300\u0026ndash;500\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85\u0026ndash;112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e31-33.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e459\u0026ndash;1065\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e11.54\u0026ndash;28.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e1.35\u0026ndash;2.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e4668\u0026ndash;33760\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient status during delivery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"+\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGestational weeks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDry weight (kg)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNeonatal status at birth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIndication for delivery\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e27\u0026thinsp;+\u0026thinsp;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBirth weight 680 g with Apgar scores of 9 at 1 minute and 10 at 5 minutes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSingle umbilical artery with elevated umbilical artery resistance and fetal distress.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e27\u0026thinsp;+\u0026thinsp;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBirth weight 650 g with Apgar scores of 8 at 1 minute and 9 at 5 minutes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInevitable abortion and polyhydramnios.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"+\" colname=\"c2\"\u003e \u003cp\u003e37\u0026thinsp;+\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBirth weight 2650 g with Apgar scores of 9 at 1 minute and 10 at 5 minutes.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDelivered at term.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study reports three successful deliveries in pregnant women on MHD and synthesizes dialysis-related pregnancy management experience from 2012\u0026ndash;2022. Optimized dialysis protocols (increased frequency to 4\u0026ndash;5 sessions/week), strict fluid balance control, anemia correction (hemoglobin target 100\u0026ndash;110 g/L), and thromboprophylaxis (low-dose aspirin), combined with multidisciplinary care, fetal monitoring, and individualized management, may improve outcomes. Although only one patient achieved full-term delivery, all mothers and infants were safely discharged with normal infant development. These results provide clinical evidence that systematic interventions may achieve favorable outcomes in high-risk pregnancies, although improving term delivery rates remains a key research priority.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Importance of multidisciplinary collaboration and comprehensive care\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe management of pregnant MHD patients requires close multidisciplinary collaboration to achieve a delicate balance between maternal stability and fetal well-being. In this study, all three patients with CKD and multiple comorbidities achieved successful deliveries through individualized dialysis regimen optimization and meticulous clinical management. These outcomes suggest that optimized management strategies may improve pregnancy outcomes in this high-risk population.\u003c/p\u003e \u003cp\u003ePrevious studies have reported successful pregnancies in MHD patients and proposed various strategies to improve outcomes, including intensified dialysis, multidisciplinary care, anemia correction, blood pressure control, fluid balance management, an unrestricted diet, and low-dose aspirin for thrombosis prevention [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u0026mdash;all of which were effective in our three cases. Our study advances this field through several key innovations. First, we developed a pregnancy-specific dry weight assessment system and established weekly weight‒gain curves on the basis of China's WS/T 801\u0026ndash;2022 standard [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], which better reflects gestational physiological changes than the fixed-weight approach reported by Yu et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Second, we determined that hemoglobin levels exceeding 110 g/L necessitate concurrent anticoagulation regimen adjustments, thereby expanding Cabiddu et al.'s anemia-thrombosis management framework [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Finally, we provide the first comprehensive documentation of full-term delivery management in this population.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Challenges in full-term delivery rates\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSuccessful pregnancy in MHD patients has historically been challenging due to maternal hemodynamic instability and low fetal survival rates. However, the number of reported cases of successful deliveries has increased in recent years. Between 2012 and 2022, 22 cases were documented (supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e), all involving pregnancies detected after dialysis initiation that resulted in live births. Notably, in 2016, Seker et al. reported a patient who achieved two successful pregnancies during dialysis [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In 2021, Medeiros et al. described a 32-year-old patient who was diagnosed with a twin pregnancy 4 months after dialysis initiation and who delivered two healthy males via cesarean section at 34\u0026thinsp;+\u0026thinsp;6 gestational weeks [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Only two reported cases reached full term (\u0026ge;\u0026thinsp;37 weeks), with the majority being preterm deliveries. Treatment regimens varied significantly across cases, with dialysis intensification protocols ranging from 3\u0026ndash;7 sessions weekly (3\u0026ndash;5 hours per session). Cesarean delivery predominated as the birth mode. Despite the increasing number of case reports, pregnancy in dialysis patients remains a rare and high-risk clinical scenario. While successful delivery is achievable, the persistent predominance of preterm births underscores the critical need to improve full-term delivery rates\u0026mdash;a major unmet challenge in this field.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Role of dialysis intensity\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study contributes to the ongoing debate regarding the relationship between dialysis duration and successful pregnancy outcomes in women on MHD. Current evidence, including meta-analyses by Piccoli et al. and cohort studies by Hladunewich et al. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], suggests that increased dialysis frequency and duration (\u0026gt;\u0026thinsp;36 hours/week) correlate with higher live birth rates and improved fetal survival. Our findings both support and challenge aspects of this dose‒response relationship.\u003c/p\u003e \u003cp\u003eIn this study, Patient 3, who underwent intensified dialysis (escalating from 3\u0026ndash;5 sessions/week, totaling\u0026thinsp;~\u0026thinsp;20 hours/week), achieved full-term delivery\u0026mdash;aligning with prior observations that extended dialysis improves outcomes. This finding supports the hypothesis that enhanced uremic toxin clearance and improved fluid/electrolyte balance mitigate placental insufficiency and fetal growth restriction. However, Patient 2, despite receiving 4 sessions/week (~\u0026thinsp;16 hours/week) after gestational week 22, delivered preterm at 27 weeks, suggesting that dialysis duration alone may not guarantee term delivery. This challenges the linear dose‒response model, implying that other factors (e.g., residual kidney function, underlying etiology, or individualized dry weight management) play critical roles. Similarly, contradictory evidence exists. Li and Guo reported successful full-term deliveries with only 17.5 weekly dialysis hours (five sessions of 3.5 hours) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], whereas Yu et al. reported preterm delivery at 34 weeks despite 28 weekly dialysis hours\u0026mdash;the highest duration in our analysis [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. These conflicting observations underscore the need for further investigation to determine whether a strict relationship exists between dialysis duration and term delivery probability.\u003c/p\u003e \u003cp\u003eNotably, Patient 1 was dialyzed 3\u0026ndash;4 times/week (12\u0026ndash;16 hours/week) and delivered preterm, further complicating the relationship. While her dialysis duration was below the proposed \"optimal\" threshold, her residual urine output (500\u0026ndash;1500 mL/day) may have partially compensated for her reduced dialysis efficacy. This underscores the need to consider residual kidney function alongside the dialysis dose, as it contributes to solute clearance and fluid homeostasis.\u003c/p\u003e \u003cp\u003eThis study highlights that while increased dialysis duration is beneficial, it is not the sole determinant of success. A multifactorial approach\u0026mdash;integrating dialysis intensity, volume management, anemia correction, and fetal surveillance\u0026mdash;is essential. Future research should explore whether a minimum threshold of dialysis hours exists for viable pregnancies and how patient-specific factors modulate this relationship. Our cases reinforce the value of personalized regimens over rigid adherence to generalized dialysis targets.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Potential of HD/HDF therapy\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe integration of HD with hemodiafiltration (HDF) represents a compelling yet underinvestigated approach for improving pregnancy outcomes in dialysis-dependent women. While our study focused on intensive HD regimens, emerging case reports suggest that combining HD with HDF may offer distinct advantages for this vulnerable population. Analysis of the 22 reported cases revealed that five patients received HDF therapy (supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e). Notably, two full-term deliveries [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], along with one vaginal delivery at 36 weeks gestation [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], all employed a dialysis regimen consisting of four weekly HD sessions supplemented with one HDF session. This suggests that a 4HD+1HDF weekly protocol may increase the likelihood of term delivery. The theoretical benefits stem from the unique capacity of HDFs to remove middle-molecule toxins and inflammatory mediators through convective transport, potentially addressing two critical challenges in pregnant dialysis patients: uremic toxin accumulation and chronic inflammation.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, the enhanced clearance profile of HDFs could translate into several meaningful improvements. First, its superior removal of middle-molecule toxins might reduce placental inflammation and oxidative stress, which are factors implicated in preterm birth and fetal growth restriction. Second, the improved hemodynamic stability of the modality may help maintain adequate placental perfusion during dialysis sessions, a crucial consideration given the heightened risk of intradialytic hypotension during pregnancy. Third, by more effectively clearing proinflammatory cytokines, HDFs could mitigate the systemic inflammatory state that contributes to adverse pregnancy outcomes.\u003c/p\u003e \u003cp\u003eHowever, the current evidence remains limited to anecdotal reports and small case series, with significant gaps in our understanding. Critical questions persist about optimal treatment parameters, including the ideal frequency of HDF sessions, appropriate convection volumes, and potential nutrient losses that might affect fetal development. The absence of robust randomized controlled trial data leaves clinicians without clear guidance on implementing this approach in clinical practice.\u003c/p\u003e \u003cp\u003eMoreover, the choice of dialyzer may represent another factor influencing pregnancy success. Among the seven cases reported by Xia et al. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], four patients maintained their prepregnancy high-flux dialyzers, which is a practice that conflicts with the recommendation for small-surface-area dialyzers [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Whether high-flux dialyzers can improve the intrauterine environment and thereby increase pregnancy success rates requires further investigation.\u003c/p\u003e \u003cp\u003eFuture research should prioritize well-designed clinical trials comparing intensive HD alone versus combined HD/HDF regimens in pregnant dialysis patients. Such studies should evaluate not only traditional outcomes such as gestational age at delivery and birth weight but also mechanistic endpoints, including inflammatory marker profiles and placental function assessments. Additionally, research must address safety considerations specific to pregnancy, particularly regarding the potential for increased nutrient loss across the dialyzer membrane. Until more definitive evidence emerges, HDF remains an intriguing but unproven option that warrants careful consideration in the context of individualized patient care.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Risks of preterm birth, congenital anomalies, and neonatal complications\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAn additional finding of this study suggests that, in addition to higher prematurity risks and occasional congenital anomalies, the incidence of neonatal complications may be relatively low. A retrospective analysis of 17 infants born to 16 mothers who were undergoing dialysis between 2003 and 2016 revealed that [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], compared with 51 gestational age- and sex-matched controls, these neonates had no increased risk of additional complications despite their elevated prematurity rates and certain congenital abnormalities. These findings align with the outcomes observed in the 22 cases presented in Section \u003cspan refid=\"Sec18\" class=\"InternalRef\"\u003e3.2\u003c/span\u003e. Although our study sample size was limited (n\u0026thinsp;=\u0026thinsp;3), no abnormalities or complications were detected in these infants.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e3.6 Fluid status and dry weight monitoring challenges\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe accurate assessment of fluid status and dry weight in pregnant patients undergoing MHD presents several unique clinical challenges that complicate management decisions. The physiological changes associated with pregnancy itself significantly interfere with traditional assessment methods [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], as the expected 40\u0026ndash;50% increase in blood volume, uterine enlargement, and fetal/amniotic fluid growth make distinguishing between normal gestational weight gain and pathological fluid overload difficult. This complexity is further compounded by pregnancy-related peripheral edema [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], which may be indistinguishable from uremia- or cardiac-induced fluid retention on the basis solely of clinical examination.\u003c/p\u003e\u003cp\u003eCurrent monitoring tools have important limitations in this population. While bioimpedance analysis and inferior vena cava ultrasound are valuable for assessing volume status in nonpregnant patients, their accuracy in pregnancy remains questionable due to anatomical changes and a lack of pregnancy-specific reference ranges. Biochemical markers such as NT-proBNP become less reliable as normal pregnancy elevates baseline levels, whereas hemodynamic instability during dialysis sessions\u0026mdash;particularly the risk of intradialytic hypotension\u0026mdash;creates additional challenges in balancing adequate fluid removal against maintaining placental perfusion [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe clinical decision-making process is further complicated by significant interpatient variability in residual kidney function, as demonstrated by the marked differences in our case series. Patients with preserved urine output may tolerate different fluid management approaches than anuric individuals do. Additionally, the absence of pregnancy-specific guidelines for dry weight adjustment in dialysis patients forces clinicians to rely heavily on individualized clinical judgment and multidisciplinary collaboration involving nephrologists, obstetricians, and dialysis nursing staff. Future research should focus on developing validated pregnancy-specific assessment tools and protocols to better navigate these complex clinical scenarios.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e3.7 Limitations\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study has several limitations. First, the assessment of volume status relies on subjective indicators such as body weight and blood pressure, and objective measures such as bioimpedance or ultrasound-derived inferior vena cava diameter are lacking. Second, the small sample size (n\u0026thinsp;=\u0026thinsp;3) from a single center and the wide gestational age range introduce potential selection bias, necessitating future multicenter studies. Third, the mean follow-up period of three years for infants only allowed evaluation of short-term growth and development, leaving long-term neurocognitive outcomes uncertain. Fourth, in Patient 2, late pregnancy detection (22 weeks) delayed intervention, underscoring the need for a structured menstrual cycle monitoring system in women on dialysis. Finally, no standardized psychological assessment tools are used to evaluate or address patients' mental health status.\u003c/p\u003e \u003cp\u003eFuture research could focus on the following directions. First, intelligent volume monitoring devices (e.g., bioimpedance analyzers) could be incorporated to establish dynamic dialysis prescription models. Second, the optimal dosing for combined low-molecular-weight heparin and aspirin anticoagulation should be explored to balance bleeding and thrombotic risks. Third, multicenter cohort studies should be conducted to validate whether the \"early pregnancy detection\u0026thinsp;+\u0026thinsp;intensified dialysis\" model improves full-term delivery rates. Fourth, investigating whether a dialysis regimen of four HD sessions plus one HDF session per week enhances the likelihood of full-term births in this patient population is important.\u003c/p\u003e \u003cp\u003eThe integration of bibliographic data follows a narrative synthesis approach, drawing on case reports and cohort studies relevant to our cases. While this provides clinical context, it does not constitute a systematic review. Future work should include systematic reviews or meta-analyses to strengthen generalizability.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Conclusions","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThis study demonstrated the feasibility of pregnancy in MHD patients through three successful cases, highlighting our comprehensive management approach. Key strategies include 1) optimizing maternal\u0026ndash;fetal hemodynamics through balanced dialysis; 2) adjusting individualized regimens on the basis of multimodal monitoring; and 3) systematically managing complications (fluid balance, anemia, thrombosis) with integrated perinatal care. The analysis of published cases suggests that a combined HD/HDF regimen (4HD+1HDF weekly) may increase full-term delivery rates. While providing practical guidance for managing pregnant MHD patients, delivery timing should be determined through individualized risk‒benefit assessments that consider both maternal and fetal indicators rather than the pursuit of full-term delivery as a universal goal.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBP, blood pressure\u003c/p\u003e\u003cp\u003eESKD, end-stage kidney dysfunction\u003c/p\u003e\u003cp\u003eHD, conventional hemodialysis\u003c/p\u003e\u003cp\u003eHDF, hemodiafiltration\u003c/p\u003e\u003cp\u003eMHD, maintenance hemodialysis\u003c/p\u003e\u003cp\u003eICU, intensive care unit\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e All authors made a significant contribution to the work reported, whether in the conception, study design, execution, acquisition of data, analysis and interpretation, or all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; agreed on the journal to which the article has been submitted; and agreed to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This work was supported by the Shenzhen Clinical Research Center for Urology and Nephrology (LCYSSQ20220823091403008), Guangdong Basic and Applied Basic Research Foundation (2023A1515111112), Shenzhen High-level Hospital Construction Fund and Peking University Shenzhen Hospital Scientific Research Fund (KYQD2024366).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstitutional Review Board Statement:\u0026nbsp;\u003c/strong\u003eThis study was approved by the Clinical Research Ethics Committee of Peking University Shenzhen Hospital (Case2025--013) and conducted in accordance with the ethical principles of the Declaration of Helsinki and China\u0026rsquo;s \u0026quot;Ethical Review Measures for Biomedical Research Involving Human Subjects.\u0026quot; All participants provided informed consent, and anonymity and confidentiality were ensured. All participants provided broad informed consent for noncommercial research use of their data. As a retrospective analysis, the ethics committee granted an exemption from written informed consent. No personally identifiable information was used, and the study posed no additional risks to the participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement:\u0026nbsp;\u003c/strong\u003eWritten informed consent was obtained from all the subjects involved in the study. The patients provided written informed consent for the publication of their personal or clinical information, including any identifiable images, in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement:\u003c/strong\u003e The raw data are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e We are grateful to all our colleagues in the clinical departments and laboratories. We thank Shenzhen OpenScience Technology Co., Ltd. for their assistance in polishing this languge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e The authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLiao Y, Wang A, Sui W, Khan A, Xiong Z, Yang G. Involuntary Falls in Patients with Chronic Kidney Diseases on Nephrology Wards: Research Advances and Future Perspectives. Nursing: Res Reviews. 2024;14:1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHladunewich M, Schatell D. Intensive dialysis and pregnancy. Hemodial Int. 2016;20(3):339\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThompson S, Marnoch CA, Habib S, Robinson H, Pauly RP. A successful term pregnancy using in-center intensive quotidian hemodialysis. 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Breaking the Barrier: Achieving Term Delivery Following 11 Years of Hemodialysis - A Clinically Significant Case (Chinese Edition). J Chin Physician. 2018;20(2):305\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo L, Xu J, Gao X, Sun Y, Pu L. Nursing Management of Pregnancy in a Uremic Patient Receiving Maintenance Hemodialysis: A Case Study (Chinese Edition). Chin J Nurs. 2018;53(6):756\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y. Spontaneous Delivery in a Maintenance Hemodialysis Patient: A Case Report​ (Chinese Edition). Henan Med Res. 2019;28(15):2879\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXia Q, Zhang P, Sheng K, Ren P, Song Y, Zhai L, Chen J. Pregnancy Outcomes in Maintenance Hemodialysis: Institutional Experience (7 Cases) and Meta-Analysis of 169 Published Cases (Chinese Edition). Chin J Nephrol. 2018;34(10):759\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReddy SS, Holley JL. Management of the pregnant chronic dialysis patient. Adv Chronic Kidney Dis. 2007;14(2):146\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eImai K, Wada M, Ogawa M, Tsuchiya K, Kusuda S. Neonatal Outcomes of Infants Born to Women on Hemodialysis: A Single-Center, Case-Control Study. Am J Perinatol. 2023;40(7):741\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoma-Pillay P, Nelson-Piercy C, Tolppanen H, Mebazaa A. Physiological changes in pregnancy. Cardiovasc J Afr. 2016;27(2):89\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhraibi AA. Renal interstitial hydrostatic pressure and sodium excretion in hypertension and pregnancy. J Hypertens Suppl. 2002;20(3):S21\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavison JM. Edema in pregnancy. Kidney Int Suppl. 1997;59:S90\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMinhas AS, Rooney MR, Fang M, Zhang S, Ndumele CE, Tang O, Schulman SP, Michos ED, McEvoy JW, Echouffo-Tcheugui J et al. Prevalence and Correlates of Elevated NT-proBNP in Pregnant Women in the General U.S. Population. \u003cem\u003eJACC Adv\u003c/em\u003e 2023, 2(2).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hemodialysis, pregnancy, nursing, delivery, uremia","lastPublishedDoi":"10.21203/rs.3.rs-8993843/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8993843/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePregnancy success rates in women on maintenance hemodialysis (MHD) have improved, but adverse outcomes remain common. We present three cases of successful deliveries in pregnant MHD patients, supplemented by a narrative synthesis of literature to highlight key management strategies. The patients had MHD durations ranging from 2 months to 10 years. Key dialysis parameters (frequency, duration, intensity) were optimized to balance maternal hemodynamics and fetal‒placental perfusion, guided by comprehensive clinical, laboratory, and fetal monitoring. Multidisciplinary management, including strict fluid control, anemia, and thrombotic risk management, alongside tailored medication, diet, and psychological support, aimed to ensure perinatal safety. Despite efforts to prolong gestation, only one pregnancy reached full term, while the other two delivered preterm. All mothers and infants were discharged without major complications, with normal infant development and steady growth observed. Optimized MHD management during pregnancy can improve delivery outcomes and neonatal survival. This study offers a clinical reference framework for managing pregnant MHD patients.\u003c/p\u003e","manuscriptTitle":"Optimized Management for Successful Pregnancy Outcomes in 3 Patients on Maintenance Hemodialysis: A Case Series with Narrative Synthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 08:44:06","doi":"10.21203/rs.3.rs-8993843/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb3d9cf7-f2c2-4d34-be11-06df4a9ae084","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-07T07:42:28+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-25 08:44:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8993843","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8993843","identity":"rs-8993843","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}