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Dr. Chapa’s OBGYN Clinical Pearls
RAFT Realities: “Robbing Peter to Pay Paul” ? (July 2026 Data)
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Jurassic Park Quote Speaker
Yeah, but your scientists were so preoccupied with whether or not they could, they didn't stop to think they should.
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Dr. Chapa
Yeah, we all should. As medical healthcare professionals, we should all strive, we should all desire scientific and medical discovery and new therapies. We should champion that. After all, that's one of the big goals of the scientific process. Process to bring new therapies to otherwise things that would be considered lethal, fatal, terminal. After all, isn't that the story of HIV and AIDS in the 1980s and 90s? I mean it was a death sentence, right? Somebody had hiv, they would soon without fail, invariably with time develop aids. And then it was a death sentence. But not anymore. I mean HIV is a 100% manageable chronic condition with appropriate medications and follow up and that is a victory of scientific and medical discovery. That's what we should do. But sometimes there's some interventions or some discoveries where you really have to question Just because we can do something raises the question if we should. Let me put this in perspective. Historically and traditionally up to still now anhydramniose, lack of amniotic fluid under around 22 weeks was considered uniformly fatal. And the reason is of course the direct correlation between lack of fluid around the child in the pre viral interval and lung development. I mean there's lung hypoplasia. You need that volume to be taken in by the child and not only go down the GI tract but go down the respiratory tract, the early pseudo glandular and canalicular, the early alveolar stage and help with lung development. No fluid especially under 20 weeks, no lung development. That was considered just not survivable. As of now, ACOG and SMFM still consider serial amniocentesis to put fluid back 100% experimental and should only be done under the setting of a trial like the RAFT trial that we're going to talk about here. RAFT stands for renal andhydramniose fetal therapy. Okay, raft like the raft on the water. But is this a real advancement without any kind of hindrance is a separate question. This may be an issue of robbing Peter to pay Paul as the classic biblical analogy goes. And most people understand that that's never applied in a good situation. Right. It's basically taking one set of problems and exchanging for another set of problems. This just came out at the start of July 2026 and it's already making headlines. I mean, and it should. This is a remarkable scientific discovery and engineering. But as Malcolm stated in the original Jurassic park, you know what scientists can sometimes Dr. Doing and end up do doing sometimes should be paired with the question, should we be consider what we're doing before we actually do it?
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Jurassic Park Quote Speaker
Yeah, yeah. But your scientists were so preoccupied with whether or not they could, they didn't stop to think if they should.
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Dr. Chapa
So in this episode we're going to talk about something that's making headlines. It's been on MedPage, it was on ACOG, you know, headlines today. Because this is a big deal, because the headline. Let me just read you the headline before we, before we leave the intro that was on MedPage and let you know how there's so much great click bait here, but you really need to know the details because here the devil is in the details. On July 1, 2026, out of MedPage, the Medical News site, quote, amnio infusions mitigate lethal lung hypoplasia from fetal kidney failure. End quote. You're like, oh my gosh, we have arrived. I mean this is like a stepping on the moon. I mean if we can put fluid back and the kids lungs are born, you know, are born, are developed when the kid is born. I mean the kid can live. I mean really, lung hyp, hypoplasia is one of the main issues here, but boy is it deeper than that. So we're going to get into this here. We're going to talk about raft, renal anhydramniose, fetal therapy. This was a remarkable study. Again, I'm not bashing this at all. It was open label parallel group prospective, but it was non randomized of course, because this is a Rare issue that followed anhydramniose under 26 weeks of gestation with serial amnioinfusions. And though the numbers were very, very small, I'm gonna Show you why Sur as a primary endpoint up to day 14 really is a low bar when you consider that there's so many things that happen after that. And I'm going to tell you what happened after that up to about day 90 of life, which is the secondary outcome that they followed up here. Right. So we didn't get into this. Can we put fluid back in anhydramniose to get the child to be born alive and have some kind of quality of life? That is the big question. Because. Let me just spoil it here for a minute. Can we get that child to an EGA where it can be born alive? Yeah, we can. The question is, what happens thereafter? Even the authors say, Whoa, whoa, whoa, whoa. This may be an issue of robbing Peter to pay Paul. They don't say it in those words. I'm gonna tell you exactly how they say it in a much more scientific way. But be careful what we ask for just because we have the technology to do something. And I'm not making. You know, I'm not saying that this is not valid. I'm just saying it's very complicated and it's devastating to tell a patient. We have one right now, guys, just so you know, we have one that was 18 weeks with no fluid and does not think that she ruptured. And repeat test of ROM plus, which is the amateur competitor, looking for biomarkers. Looks for alpha feta protein and insulin like factor binding protein 1 have been negative. Right. There's just no fluid around that child at 18 weeks and it's not getting better. So this is a devastating condition. And the question is, what do we do here right now? Amnioinfusions serially. Okay. To keep fluid in that cavity is considered experimental. But I'm going to show you what RAFT kind of opened the door to. And I'm not saying it's wrong at all. I'm just saying it's something for us to consider. Just because we can do something, sometimes we have to ask, should we?
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Jurassic Park Quote Speaker
Yeah, but your scientists were so preoccupied with whether or not they could, they didn't stop to think if they should.
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Dr. Chapa
I think I've set it up enough. Podcast family. Let's come back and talk about Raft realities. Is this robbing Peter to pay Paul? We will be right back. We're just trying to fulfill our life calling and our mission. This is Dr. Chapa's OBGYN no Spin podcast. I do absolutely have to congratulate these physicians, these scientists that are thinking outside the box to bring some kind of Hope here to EPRA. Okay? EPRA, that's the other term here, EPRA. You're going to see that in some literature, EPARA stands for early pregnancy renal anhydramnios. Okay? EPARathhat is early pregnancy renal anhydramnios, meaning there's no fluid here and it's from a renal source, meaning it's not. Because they ruptured. If they're ruptured, y', all, that's a separate issue, y', all with me here. So if they have, you know, rupture of membranes at 18 weeks because it's under 20, that's still considered an abortion, right? Now, she can choose expectant management if she likes. And there's some data that say give them antibiotics, too. Even though ACOG says start at 20 weeks, there is some data that those who rupture under 20 weeks can have antibiotics for latency. That's not the norm, though. And to be clear, it's not the norm. ACOG said you can consider antibiotics starting at 20 weeks, but in general, under 20 weeks is considered. That's an abortion, right? If they rupture by themselves. But this is not the case. These are not patients that are ruptured. These are anhydramnios from some renal source. Now, in some renal source, we got two buckets here. We've got renal agenesis. I mean, now that's a separate. A separate issue. I mean, if you don't have kidneys, you know, you can put fluid back. And that's a separate study here through raft. But, you know, the child has no kidneys, so that's going to require peritoneal dialysis at birth. And of course, it's going to require renal transplant, which you can see how complicated and rare that is. Okay, so there's renal agenesis. That is bra, the bra cohort. Bra, like your bra is showing. Okay? Bra. That stands for bilateral renal agenesis. That was not. This study. This study from July 2026 is looking at renal failure. So they've got kidneys seen on ultrasound, but they're not working for some reason. Maybe they're, you know, they've got some kind of vascular issue. They could be polycystic issues, whatever. They got some kind of renal failure. And I'll tell you the inclusion and exclusion here, but these are not renal agenesis these have kidneys, but there could be some. A post bladder uropathy, some obstruction, whatever. The fluid is not coming out. So some kind of renal failure, even though they've got kidneys present. All right, so under epra, early pregnancy, renal anhydramniose, you've got the BRA cohort, renal agenesis, and then the renal failure. This is looking at renal failure. So now that we've said that, just as a reminder, ACOG and SMFM currently state that pre viable anhydramiose is pretty much lethal here with a, you know, shared decision making with a patient if they want to continue. But that amnu infusions are considered experimental and quote, should only be considered under a clinical trial setting, end quote. I'm doing that exactly from the wording. Okay? Now all of these cases, if you find anhydramnios and she is not ruptured, you gotta see the anatomy of this child. You gotta see if there's some other issue going on here. Cause sometimes the kidneys are the first flag and sometimes you can't see well because there's no fluid. So in order to get a good detailed ultrasound evaluation, it is not unusual to put fluid in as a diagnostic amnio, not to take fluid out, to put fluid in as a diagnostic amnio, in order. So you can do an ultrasound, but that's not therapeutic. All right, that's done for ultrasound diagnostic purposes. It's not done all the time, but it is a thing. Just so you know, if there's no fluid in there and you suspect it's coming from a renal sore, some kind of EPARA situation, early prenatal, early pregnancy, renal anhidramnios, and they're not ruptured. You can put fluid in and try to do an ultrasound to better check what's going on. That's done percutaneously through the abdomen. You can do that. Okay. Now, of course, these also need detailed genetic evaluation that can include karyotype. They need microarray. Sometimes you could do whole exon sequencing. ACOG doesn't do that routinely. But for these weird conditions, you know, depending on the presentation, this is where one of these things you can do to look for some other weird chromosomal issue across the entire genome. All the different chromosomes, not just the typical trisomies. All right, so you need good detailed anatomical review that may include putting fluid back in percutaneously and some kind of genetic eval using either microarray. You can at least karyotype or whole exon sequencing. All right? So EPRA either as renal and hydramnios from renal failure or bilateral renal agenesis. This study is looking at renal failure again, July 2026, non randomized open label. It was a parallel group looking for those who had no fluid so they could start treatment before 26 weeks. Okay. Now, there was, as I mentioned before, there was originally two patient groups. One was a bilateral renal agenesis. But in this study, which is looking at the renal failure group, we're talking about a total N, a total study number of babies here of fetuses that are 32. Okay, so it's not a big number because it tells you how rare this is. So it's an N of 32. And then they have to qualify for this and want serial amnioinfusions. Now, as a big aside, just so we know and put it out there in the open, 94% of these participants. Right. So 94% of these women that carried these pregnancies with no fluid identified as white. That's 94%. Which lets you know, is there social barriers here? The patients who only speak Spanish not understand the conversation, whatever. I don't know. But they do mention here the limitation here is maybe some social, political, or socioeconomic barriers because 94% here identified as white. All right, fine. Having said that, these did have a screening diagnostic mu infusion performed so that they could look for other issues. Plus they had to make sure that these patients did not have rupture. So, yes, while you're doing it, to put fluid in so you can do your ultrasound. And advantage of doing that also is that if the fluid that you put in comes out of the vagina. So some people sometimes put a little bit of like, you know, indigo, not methylene, because methylene could be toxic to the developing GI tract, but a little bit of like indigo, carmine is something to diet and it comes out of the vagina. Then they know, well, it's probably not a renal source, but it looks like you are ruptured. So it's also diagnostic and helpful to get to figure out if they really are ruptured and this didn't know, or if it's coming from some other kind of EPRA situation. Remember early pregnancy renal anhydramnios? Okay, so the inclusion criteria, these patients had to be at least 18. Makes sense. They had to be singleton gestation and they had to have anhydramnios detected at less than 22 weeks with the beginning of therapy before 26 weeks. Right. So these are all at a crucial time where that fluid must be present to help that early canalicular phase of lung development happen so that the lungs can have some chance of developing here. All right, so they had to have this detected under 22 weeks. Now here it is. It had to be attributed to fetal kidney failure and not due to bra to bra. Now, as for exclusion criteria, that included the presence of any other significant extraarenal congenital fetal anomaly. So if it also had, let's say, you know, an encephaly, I'm just saying, then that's not going to be included here. If they had suspected autosomal recessive polycystic kidney disease that, you know, looked. If they looked polycystic on ultrasound, they were excluded because that tends to be. Have a component of multisystem involvement with other issues. So it wouldn't be a clean study. So they were excluded. It had to be just, kidneys look like they're present, but they're just not working. All right, so earlier I said that polycystic kidney disease can be a cause of kidney failure. That is absolutely true, but they were excluded for this part of the RAFT study. So in other words, it looks like you got kidneys, looks like they look normal, but they're just not functioning from some other issue. Okay, so exclusion was that they were ruptured, they had some other congenital fetal anomaly, they have suspected polycystic kidney disease, and. Or if they have a known abnormal genetic issue that's not compatible with life, then obviously that's not going to happen here. Now, if they had some other contraindication to serial tapping of the amniotic sac, in other words, if you suspected chorio, obviously that's a no go. If they suspected chronic abruption, no go. If they had a cervical length less than 25 millimeters, that was no go because they were trying to get, you know, deliverable, you know, past viability, not the periviable stage. So if they had a cervical infest in 25, they were not allowed. And if mom had uncontrolled diabetes or refractory hypertension or any other condition that was known to increase poor placental function or lead to iatrogenic preterm birth, they were excluded also. All right, so do we all get what we're talking about here? Oh, my goodness. You're under 22 weeks. Your poor child looks like he's got no fluid in there. And it doesn't seem that you're ruptured, and it doesn't look like there's polycystic kidney disease. And we know that your child doesn't have anything wrong genetically. As far as we know, either by nips testing or ideally karyotype or microarray, you qualify for placing fluid back into the cavity. And we should start that before 26 weeks. Okay. Unless those contraindications to doing that, like chorio placental abruption rupture or a short cervix or some maternal complications existed like diabetes or refractory hypertension, said otherwise. So if you're thinking, well, how do they do this? Well, this is transabdominal. They use either saline or lactated Ringer. It was with a 20 or 22 gauge needle. It's done under local. It's very fast. It's like taking fluid out for a diagnostic amnio. You put fluid in and at each time that they did this, and they did this repeatedly from 2 days to 12 days to keep an MVP at a certain amount, they're looking for a maximum vertical pocket. Sometimes it would be 300ml, sometimes they put up to 800mls again repeatedly from every 2 to 12 days to keep the maximal vertical pocket visible to give the chance of the lungs to develop. All right. Okay, so we get the problem, we get the intervention. Serial amnio is done transabdominally. What's the primary outcome? So there's several here. So I want to break this down very quickly. The primary outcome, the main thing that we're looking at is neonatal survival. So it means baby's born alive and survives 14 days or longer with dialysis placement to demonstrate that the lungs are functioning. So it's got to be born alive, obviously, and it's got to live to 14 days or longer and have dialysis access placement to show that the lungs work. So that's number one. If child's born alive and it lives for 14 days, that's primary outcome. Okay, that's great. But there's a lot of very important secondary outcomes. Of course, you look for maternal complications, including a rupture of membranes. And they also looked for neonatal and infant secondary issues like survival at 30 days. Yeah, that matters. 60 days, 90 days survival to hospital discharge, and then how many ended up with a kidney transplant? Okay, so let me, let me just give the historical nature of this. As we've already stated in the intro and earlier, this was horrifying. If there's no fluid, like you can't, you can't make that child breathe. I mean, there's no amount of betamethasone that's going to work here. So any hope I am for, I want this to Work, guys, I want this to work. At the same time, I don't want these children to suffer when they're born now. So I don't know. This is totally. We got several analogies here, right? Robbing Peter to pay. Paul, we've got the old statement of just because you can doesn't mean that you should. And this one is, what is the goal here? Is it survival or is it quality of life? I don't want to, to. To sacrifice ability to be, you know, to be alive at 90 days when it's going to be full of pain and suffering. I don't know. I. I'm just. I'm just. This is very physical. What am I trying to say here? I was going to say physiological. No, philosophical as well as it is medical. I don't know what the right answer here, guys. I don't know. Even the authors here at the end, when you read this very detailed publication, they kind of take a cautionary tail here. They take a cautionary note here. That, man, we're kind of trading off one serious issue, which is lung hypoplasia and inability to breathe and adopting. Other problems here, severe morbidity. So I don't know, I'm not saying it's right or wrong. I'm just giving you the reality. Let me give you the primary outcome. We're going to do this very, very quickly because the headlines again, it's clickbait, right? The medpage. Oh, my gosh. Serial amnio mitigate lung hypo. You know, functioning at birth from anhydramnios. You're like, oh, my gosh, we have solved anhydramnio's problem. Wait a minute, wait a minute. Let's get back to the primary outcome. Remember that? Survival to 14 days, okay? Of the 32 intervention pregnancies, 29. So 29 of 32 resulted in a live birth, okay? So that's. So out of the 32 that we started with, 90% got a live birth. Born alive. We'll get to the 14 days in a minute. All delivered prior to 37 weeks. It was around 31 to 34 weeks was kind of the median around there. So they got to, you know, preterm to late preterm. So 29 of 32 were born alive, okay? That's the goal, just to get them alive. Now for the primary outcome, which was survival to 14 days. So remember, we're starting here. 29. Of 32 of those 29 that were born alive, 19 achieved the primary outcome of survival to 14 days. Or longer with dialysis access. So notice what's happening to the numbers. Okay, we're having attrition already. Y' all with me here. So that's why whenever we read something, a study, and it says we have success, what is your success? What is the bar here? So born alive. All right, well, we've got 29 of 32. We do that. That's. And that's great. I'm all for that. But now look at survival, which is a primary outcome to 14 days, we go to 19 of those 29. So we're at 65%. Okay, again, I'm okay with that. That's better than nothing. But what happens to these? So 19 from 29 numbers are getting smaller. So of those three pregnancies ended in fetal demise. One was at 24 weeks. It had PPROM after the first amnio infusion. Another one was at 27 weeks. Four days of some fetal bradycardia. Four days after the amnioin fusion, those fetal bradycardia. And then at 31 weeks, again, fetal bradycardia during the 15th amnio infusion. So those were three pregnancies that ended in fetal demise. These are complicated things, guys. Now let's get back to the numbers. Remember, we had 19 of the 29 who survived to day 14. Then 14 of those 29. Okay, so notice again the numbers. We were at 19 of 29. Now we're at 14 of 29 of those live born infants survived to hospital discharge after a median of around 4.7 months. 13 of those 14. So almost all of them were receiving long term peritoneal dialysis. Okay, y' all with me here. So 32. Now we go to 29, 20. We're at number 29. 29 who are born alive. 19 of those who got to day 14. And now we're talking about of those numbers, we have those who survive to hospital discharge. All right, so 14 of those 29 were at 48% survive to hospital discharge. Numbers are getting smaller. 32 total. Then it went to from 32, it was 29 born alive. 19 of those survived to day 14. And now we're at 14 of those 29 who survived a hospital discharge undergoing long term peritoneal dialysis.
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Dr. Chapa
y'.
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Jurassic Park Quote Speaker
All.
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Dr. Chapa
I don't know if that's good or bad. I mean, it's a, it's a, it's a hope, it's a chance. I think that's better than nothing, but this is not an easy fix is what I'm getting at. All right now, of those, there's things that happened to some of these kids. One neonate had a prenatal diagnosis of lower urinary tract obstruction. It underwent in diverting vasculotomy postnatally and it had enough urine to be discharged home at four months. But they subsequently progressed to end stage kidney disease and then underwent kidney transplant by age 2. Do you all get what I'm saying? Very complicated outcomes here. Severe morbidity. Then there were three infants that died after hospital discharge. One had complications due to acute abdomen and Hirschsprung, which was another condition. One died at 14 months of respiratory failure after a diagnosis of hepatoblastoma, and then one at 16 months with hepatocellular carcinoma. A lot of morbidity comes here because if the kidneys aren't working, the body kind of goes away. All right, all I'm saying, I'm not saying, I'm not trying to knock this down. I'm saying there's severe issues here if the child gets on the kidney transplant list. Okay, now remember the secondary outcomes. We're almost done here. We're almost done because I know this is a lot to process. The secondary outcomes were survival to age 30, 60, and 90 days. Let me give you those percentages real quick. Survival to age 30, that was an N of 17. Survival to day 60, that was an end of 16. And then at 90 days, it was an end of 14. Okay, so you're like, okay, so I mean, I guess that's okay. That's 48% of that entire cohort that was treated. Now from a family social issue, remember? Look at all the social anxiety that comes from this 87% reported sometimes are always feeling anxious and 100%, obviously, sometimes, often or always worried about their child's future. End quote. Y', all, I don't know. I care for these little babies so much, you know, in utero. I want these things to work, but I don't know, I don't know what the answer is. Here is this, do we celebrate this? Do we look at this cautiously? I don't know. It's a very difficult issue. Look, so here's a plus and then here's the minus. And then we're gonna wrap this up. Okay, so great discussion to have as journal club, by the way, but it does raise an important question. Just because we can do something, should we. I don't know. It's like resuscitation. This same argument is for neonatal resuscitation at, you know, 21 to 22 weeks. I don't know. I mean, what is our out ultimate outcome here? Is it survival to discharge? What about quality of life? What happens after discharge? So it depends how you look at success. Depends on where you set the bar and what your target is. So let me give you their overall conclusion and then I'm going to tell you their caveat here. They're kind of, they're punching the brakes here. They're like, well, we didn't expect this, by the way. There are also some children here who develop strokes. There is an association between renal agenesis or renal failure in a fetus and early neonatan stroke, probably because of vascular dysregulation. There's volume shifts. So there is absolutely an association with stroke which also happens to some of this cohort. Okay, serious stuff here, serious stuff here. So the overall conclusion quote in this non randomized open label parallel group prospective clinical trial, serial amnioinfusions beginning before 26 weeks for maternal fetal pairs with anhydramnios due to fetal kidney failure without agenesis mitigated, otherwise lethal neonatal pulmonary hypoplasia. End quote. That sounds great, right? That's what got picked up by the headlines. Hey, we can reduce lethal neonatal pulmonary hypoplasia. But they go on to say, quote, however, that however, guys, is heavy. All right? Quote. However, this path is burdened. Look at that word. Not as complicated by not is, you know, parallel with or whatever. No. Is burdened by prematurity and significant long term morbidity, underscoring the necessity of thorough nuanced counseling for families considering this intervention. End quote. So the take home is. Are we robbing Peter to pay Paul. We can help the lungs, but at the expense of stroke, at the expense of some serious other infections and or conditions. I don't know. So while this is. We should celebrate this victory. We've made a dent into severe pulmonary hypoplasia from anhydramniose. But it doesn't take the fact that the kidneys aren't working in the child, and that's gonna need long term peritoneal dialysis. If they're lucky enough, of course they'll get a kidney transplant. I don't know what the right answer here is.
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Jurassic Park Quote Speaker
Yeah, yeah, but your scientists were so preoccupied with whether or not they could, they didn't stop to think if they should.
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Dr. Chapa
I don't know. And again, I'm not trying to make this a ethical issue. That's its own separate discussion. I don't know. When I first read this, I'm like, phenomenal. What is that? Raft came out all right. What did it show? It makes sense to me. If there's no fluid, put fluid back. And that takes care of the lung issue. Yes, we can cover that. We can mitigate that risk. But there's other things that go into that that even pop up later, because if the kidneys aren't working as a vital organ, it sets the system up to other cascade issues for other poly system dysfunction. I don't know, guys. I just wanted to throw that out there. Something to consider. So I call this Raft Realities. Paying. Robbing Peter to pay Paul. We take from one issue to give to the other. I don't know. Not saying it's a bad idea, just saying, as they said in their own words, it's complicated. It's burdened by long term morbidity. And this requires nuanced conversation, which is why it is still, as of right now, as of July of 2026, considered experimental podcast family. As always, we're thankful for you. We're glad you're part of our podcast community, Michael. This was deep, man. This was real deep. Now that we've done all that, I think we're done. Let's take it home. This is Dr. Chapa's obgyn no spin podcast.