Michelle Hladunewich, MD

Dr. Hladunewich is an Associate Professor of Medicine at the University of Toronto in Toronto, Ontario, Canada. She is the medical lead for the Kidney Disease and Pregnancy Clinic (PreKid Clinic). Her research program includes studies in glomerular-based disease as well as pregnancy-related kidney disease. She is also the Selection Committee member of the Women’s Health region of NephMadness 2018.

Competitors for the Women’s Health Region

Reproductive Planning vs Menopause in CKD

Preeclampsia’s Global Impact vs Prematurity’s Global Impact

The World Health Organization defines reproductive freedom as the basic right of all individuals to decide freely and responsibly the number, spacing, and timing of their children, to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health.

For most young women this means choosing a form of contraception that fits best with one’s lifestyle and then simply stopping it when life circumstances have aligned to create the optimal time to have a child. As a woman ages, she and her physician can decide if the symptoms of menopause are irritating or severe enough to justify hormone replacement therapy despite the known controversies, and the consequences of aging like osteoporosis can be safely treated.

Every woman has and will make these choices at some point in her life, but for women with chronic kidney disease (CKD), reproductive health is far more complex at every life stage with both contraception and hormone replacement being poorly studied and potentially unsafe, and pregnancy bringing significant risk to both mom and baby.

Women with CKD have to consider the impact of contraception on their blood pressure and underlying kidney disease, limiting choices. They need to worry that both their disease as well as the medications needed to treat it, at times, might impact future fertility. When ready to conceive, these young women must plan meticulously, as an ill-timed pregnancy can result in disease progression, a disease flare, or exposure of an unborn child to potentially teratogenic medications. Pregnancy risks for mom and baby are significant, in particular the risk of preeclampsia, which is 10-fold higher among women with CKD.

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In addition to worrying about her own future renal and cardiovascular health, these women have to also worry about the impact of pregnancy-associated complications on the well-being of their future children, as we now understand that preterm children are more susceptible to future cardiovascular disease and renal disease. This becomes a vicious cycle wherein unwell moms often have small, sick children, creating a vicious cycle of chronic disease.

Timing becomes everything for women with CKD as risk increases with each advancing stage of CKD along with advancing age, which is much to consider beyond simply ensuring one is financially stable and mentally prepared to be a parent. Women with CKD make almost impossible choices in their quest to become parents. The notion of realizing in advance you may need dialysis or a transplant simply because you want to exercise your reproductive freedom seems like a very steep price to pay for what many healthy women take for granted. Still, young women with CKD make these difficult choices everyday. These complex deliberations require support and guidance, and women with CKD need to be empowered with the necessary information to make personalized reproductive choices.

As such, it is the obligation of every nephrologist to provide this specialized care throughout a woman’s life cycle, carefully assisting in the choice of methods to prevent unplanned pregnancies, choosing treatments that preserve fertility, and participating in shared decision-making to optimize the timing of each and every pregnancy. We also need to remain engaged as our patients age, despite our lack of data of how best to help them manage the symptoms of menopause and avoid age-associated complications such as heart disease and osteoporosis.

To date, the nephrology community has not adequately assumed this role, with many nephrologists feeling ill-prepared to provide the full spectrum of reproductive care that women with CKD require. This has stemmed from fear and a lack of robust evidence, which can only be remedied by multicenter, collaborative efforts. While we wait for knowledge and enlightenment, our female patients want all the same opportunities from life as their peers – to have healthy and fulfilling sex lives, to be mothers, to age with grace.

As such, we need to be better prepared to have the tough conversations about birth control, fertility, and sexuality. Ensure that the young women in your practice know that kidney disease can impact their reproductive choices and help them navigate what is often overwhelming. Begin the conversation early in her disease course so that she can plan her life and family in the context of her CKD. Early CKD is safer for mom and baby, but later in the disease course, even on dialysis, is now possible – reproductive freedom is every woman’s right.

Remember that even after she has had her family, challenges will persist as she tries to raise her children in the context of chronic disease and maintain her health so she can be there as her children grow and have families of their own. Over the years, I have been privileged to age with my patients and I have always appreciated how easy my life choices have been relative to theirs.

This year’s World Kidney Day focused on the theme of kidneys and women’s health, with the tag line: “Include, Value, and Empower.” Let’s include all women with CKD in the conversation, let’s value their special needs and concerns, and let’s empower them with the knowledge they need to make their own reproductive choices.

– Post written by Michelle Hladunewich

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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