Nephrologists need to connect with women’s health issues and CKD
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It is critical for nephrologists to provide counseling and treatment when women’s health issues intersect with kidney disease. Much work remains.
In a study done by the Women’s Health Working Group of Cure Glomerulonephropathy, almost two-thirds of nephrologists reported they lacked confidence in management of women’s health issues, including menstrual disorders, preconception counseling, pregnancy management and menopause.
“Innovative approaches are warranted to improve the care of women with kidney disease and might include the expansion of interdisciplinary clinics, the development of case-based teaching materials and interdisciplinary treatment guidelines focused on this patient group,” Elizabeth M. Hendren, MD, and colleagues wrote.
It is not surprising that when the American Society of Nephrology Taskforce on the Future of Nephrology published the article, “Reimagining nephrology fellowship: Education to meet the future needs of nephrology” earlier this year, the authors called for development of individualized advanced training pathways in multiple areas, including women’s health.
The authors wrote, “[T]he future of kidney care will include a variety of new tools and interventions that will require exceptional clinicians to provide specialized care for extremely complex patients.”
Medications during pregnancy
Chronic kidney disease affects about one in 15 women of childbearing age in high-income countries. Counseling surrounding contraception and planned pregnancy is an important part of both shared decision-making and the patient’s nephrology care, including the effects of teratogenic medications to treat CKD. Pregnancy timing and risks all need to be considered.
Some studies have suggested up to 75% of women of childbearing age with CKD are on teratogenic medications; ideally, these medications should be stopped prior to pregnancy. That requires the pregnancy to be planned.
Risks of exposure to teratogenic medications are varied and depend on the drug but range from cleft palate to neonatal kidney failure and death. In addition, there are data on the importance of timing a pregnancy for the best outcome when patients have various types of kidney disease. In lupus nephritis, it is ideal for the disease to be quiescent for at least 6 months. In patients with a kidney transplant, it is best to wait at least a year post transplant, have adequate allograft function, no recent infections that could affect the fetus and no episodes of rejection in the past year. In advanced CKD, if a woman is young enough, it may be best to wait for a transplant or nearing the end of childbearing age.
Maternal, fetal risks
It is important to be able to counsel a woman on the maternal and fetal risks during pregnancy. As CKD progresses across the spectrum from mild to kidney failure, there is an increased risk of progression of kidney disease, new onset hypertension, preeclampsia, low birth weight and preterm delivery. Reduced fertility associated with CKD, as well as treatments that affect fertility, are also important to discuss with patients.
Contraception
Discussions surrounding contraception are an important part of counseling women of childbearing age. Unfortunately, there is a paucity of data on the safety and efficacy of the different types of contraception for women with CKD. Thus, most of the counseling we do as nephrologists is based upon theoretical concerns.
Hypertension is common across all CKD stages and may be worsened by estrogen-containing contraception products. The risk of venous thromboembolism increases as kidney function declines, and women with nephrotic syndrome are at high risk for venous thromboembolism. Contraception products containing estrogen increase the risk of venous thromboembolism.
Risk of mortality from CVD increases as kidney function declines and as albuminuria increases. It is important to remember that patients on dialysis have a high CVD mortality risk. A patient on dialysis aged 25 to 34 years has the same CVD mortality risk of an 85-year-old patient. Estrogen-containing contraceptives increase the risk of myocardial infarction and stroke and should not be used in women with significant CVD.
Estrogen-containing contraception may also increase the risk of a flare of lupus nephritis. Long-acting injectable progestin may increase the risk of venous thromboembolism and may also decrease bone mineral density (BMD).
The progestin drospirenone has anti-mineralocorticoid activity and could theoretically cause hyperkalemia in women at risk. Intrauterine devices have a rare risk of uterine perforation, which is particularly important information for women on peritoneal dialysis.
Ongoing care
The care of women with CKD does not end when the patient becomes pregnant. Ongoing meticulous nephrology care throughout pregnancy is critical. Frequency of evaluation is dependent on the degree of kidney dysfunction, as well as the underlying cause of kidney disease. Hypertension, kidney function, anemia, electrolytes, metabolic bone disease labs and proteinuria need ongoing monitoring. Initiation of hemodialysis should be considered at a higher GFR than in nonpregnant women. Women with anemia due to kidney disease are likely to have increased erythropoietin and iron requirements to avoid the need for transfusions. Low-dose aspirin therapy should be considered for preeclampsia prevention.
Menopause
Women’s health also does not end when the childbearing ages end. The prevalence of CKD increases with age, so it is also important for nephrologists to be aware of the interaction between CKD and menopause. Menopause occurs earlier in women with CKD. With earlier menopause comes the earlier harmful effects, including increased CVD risks, decreased bone mineral density and vasomotor symptoms.
Unfortunately, there is little known regarding the treatment of these sequalae of menopause in women with CKD. Kavitha Vellanki, MD, and colleagues put it best in their review of menopause and CKD when they wrote, “Lack of data and specific guidance on management make the long-term effects of menopause one of the most under-recognized and neglected patient problems in clinical nephrology.”
Next steps
We need more education, research and counseling for women with CKD who face the many health issues outlined in this article. Fortunately, this is an area of increasing interest (see the Cover Story).
The recent KDIGO Controversies Conference on Women and Kidney Health highlighted the need for future research on many issues that continue to have significant knowledge gaps. With 75 experts from more than 30 countries in attendance at the conference, it is clear the need for “more” has been recognized. Nephrologists also need to take the lead and become more comfortable with discussing these issues with their female patients.
I am optimistic that more innovation and research will lead to improvements in care for women with CKD.
- References:
- Burgner A, et al. Am J Kidney Dis. 2019;doi:10.1053/j.ajkd.2019.04.017.
- Hendren EM, et al. J Clin Med. 2019;doi:10.3390/jcm8020176.
- Mills KT, et al. Kidney Int. 2015;doi:10.1038/ki.2015.230.
- Rosenberg ME, et al. Clin J Am Soc Nephrol. 2023;doi:10.2215/CJN.0000000000000133.
- Vellanki K, et al. Am J Kidney Dis. 2018;doi:10.1053/j.ajkd.2017.12.019.
- For more information:
- Anna Burgner, MD, MEHP, is an assistant professor of medicine in the division of nephrology and hypertension in the department of medicine at Vanderbilt University Medical Center and director of the dialysis program. She is also an associate editor on the Editorial Advisory Board for Healio | Nephrology News and Issues. She can be reached at anna.burgner@vumc.org.