Severe renal insufficiency (serum creatinine greater than 2 mg/dL) during pregnancy has been associated with poor perinatal outcome. Even in the absence of maternal indications, hemodialysis has been suggested for fetal indications, although the influence of maternal renal failure on the newborn's development is unknown. The effects of the abnormal biochemical environment of dialysis on fetal growth and development are also unknown, and the small numbers of reported cases make it difficult to assess the indications for hemodialysis. A 35-year-old woman had a twin gestation and severe chronic renal failure. The pregnancy was managed without hemodialysis, and at 33 weeks' gestation two healthy newborns were delivered with cesarean section. Bailey scales of infant development at 14 months of age showed normal infant development. Hemodialysis is not indicated solely for fetal reasons in the patient with severe but stable renal failure in the absence of severe hypertension, pre-eclampsia, deteriorating renal status or intrauterine growth retardation.