Successful Management of Discordant Twin Growth in End-Stage Renal Disease: A Rare Case Report.

This case report describes the successful management of a dichorionic-diamniotic twin pregnancy in a 35-year-old woman with end-stage renal disease (ESRD) on hemodialysis. The patient had established kidney failure secondary to presumed hypertensive nephrosclerosis, complicated by a previous pregnancy with preeclampsia, and was maintained on home hemodialysis (five hours per session on alternate days) since 2022. Upon confirmation of twin pregnancy, her dialysis regimen was immediately intensified from alternate-day sessions to daily treatments totaling 35 hours/week, with parameters including five-hour duration, blood flow rate of 250 mL/min, and ultrafiltration of 1.2-1.5 kg/session. During the second trimester, maternal weight was carefully monitored alongside fetal growth, with an expected increase of 0.5-1 kg weekly. At 27 weeks' gestation, significant fetal growth discordance prompted further dialysis intensification to six times weekly with increased blood and dialysate flow rates. The pregnancy was complicated by intrahepatic cholestasis and therapy-resistant hypertension. At 31 weeks, the patient developed acute pulmonary edema with severe preeclampsia features despite optimal volume management, requiring emergent cesarean delivery of two live infants. This case demonstrates that intensive dialysis protocols are essential for achieving favorable outcomes in twin pregnancies complicated by ESRD. Success depends on three critical components: early recognition of maternal and fetal complications, intensive fetal surveillance throughout pregnancy, and precise control of dialysis parameters with frequent adjustments based on clinical status and fetal development.