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Silvi Shah @silvishah

Silvi Shah is an Associate Professor in the Division of Nephrology and Hypertension at the University of Cincinnati, Ohio. Dr. Shah is a physician-scientist, and her research focuses on women’s health in kidney disease including pregnancy, sex disparities in kidney disease, cardiovascular health, and kidney disease. She is currently supported by the K23 career development award from the National Institutes of Health.

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Belimumab vs Voclosporin

Family Planning in LN vs Pregnancy in LN

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Chronic kidney disease (CKD) affects about 3% of women of childbearing age. Lupus nephritis is an important cause of CKD. Having a child is an integral part of life for many women and this does not change for women with CKD due to lupus nephritis. Due to the higher risk of adverse pregnancy outcomes with lupus nephritis and progression of kidney disease with pregnancy, reproductive health counseling, particularly discussion of family planning, is important.

Although there is impairment of fertility with progression of kidney disease, women are still able to conceive, and one of the goals of the family planning discussion is to prevent unintentional pregnancies. Moreover, women with lupus nephritis may be on medications such as mycophenolate and angiotensin-converting enzyme inhibitors that are teratogenic or may be needing treatment with medications such as cyclophosphamide that can impair fertility; hence, the importance of counseling on family planning.

The risk of adverse pregnancy outcomes increases with worsening of kidney function, worsening proteinuria, and active lupus disease. It has been shown that for women with creatinine of 2.5 mg/dl and higher, up to 30% may need dialysis by 12 months postpartum. Furthermore, for women with chronic kidney disease stage 4-5, up to 80% may have preterm and low birthweight deliveries. As pregnancy in women with lupus nephritis is a high-risk pregnancy, it should involve care coordination with a multidisciplinary team comprising the nephrologist, maternal fetal medicine, and the neonatologist.

Counseling for family planning and contraception should be provided by the nephrologist in coordination with the obstetrician. If a woman is listed for transplant, they should be counseled regarding return of fertility and improvement of pregnancy outcomes. Women with kidney failure have low rates of contraceptive use. This could be related to inadequate counselling, lack of knowledge, and low confidence of health care professionals in managing reproductive health for women with kidney disease. The choice of optimal contraception depends on their risk profile, medication use, and presence of comorbidities. Contraceptive use should be discussed with women in shared decision-making. For women with history of cardiovascular disease and history of thrombosis, oral contraceptives are contraindicated due to the presence of estrogen in them. Barrier methods are not recommended due to their high failure rate. Usually, use of intrauterine and progesterone-only methods remain the first line contraception for women with lupus nephritis.

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In conclusion, family planning with lupus nephritis remains of paramount importance. However, there continues to be a deficit with nephrologists discussing family planning for patients with lupus nephritis. Increasing awareness and including reproductive health in nephrology curriculum are steps that may increase the confidence and incorporation of reproductive health in our clinical practices.

– Guest Post written by Silvi Shah @silvishah

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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