Abstract
INTRODUCTION: Managing pregnancy in patients with end-stage kidney disease (ESKD) undergoing dialysis is challenging, with hypoalbuminemia significantly increasing risks to both maternal and neonatal outcomes. Intensive hemodialysis regimens are recommended; however, individualized and adaptive dialysis strategies, such as sequential online hemodiafiltration (OL-HDF) and intermittent HDF (i-HDF), may be required to optimize care in complex cases. CASE PRESENTATION: We report the case of a 27-year-old Japanese woman with ESKD who transitioned from OL-HDF to i-HDF during pregnancy due to progressive hypoalbuminemia at 30 + 5 weeks of gestation. Dry weight adjustments were guided by human atrial natriuretic peptide (hANP) levels, blood pressure measurements, and bioimpedance analysis. i-HDF reduced albumin loss compared to OL-HDF, stabilized maternal hemodynamics, and enabled term delivery at 39 + 1 weeks with a healthy neonate weighing 2,774 g. Bioimpedance analysis and hANP-guided adjustments allowed for precise fluid management, resulting in a total gestational weight gain of 6.4 kg. The patient developed superimposed preeclampsia during labor, which was successfully managed. CONCLUSION: This case demonstrates that sequential OL-HDF and i-HDF can effectively address hypoalbuminemia and fluid imbalances, contributing to successful maternal and neonatal outcomes in ESKD pregnancies.