June 2024 Edition
Impact Factor 2023
ISN eDigest: Kidney Disease, Pregnancy, and Female Health in Kidney Care and Research – a Roundup of Recent Articles From ISN JournalsThis series of articles from Kidney International® and Kidney International Reports® address critical aspects of female health in kidney care, particularly the impact of kidney disease on pregnancy outcomes.
These studies highlight gaps in care for women with kidney disease and underscore the importance of multidisciplinary care and personalized treatment strategies for this population. Additionally, the need to improve the representation of women in nephrology research to improve outcomes for women with kidney disease is emphasized.
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KIDNEY INTERNATIONAL ARTICLES |
Any Reduction in Maternal Kidney Mass Makes a Difference During Pregnancy in Gestational and Fetal Outcome
As chronic kidney disease (CKD) becomes more prevalent worldwide, its incidence among pregnant women is also increasing. How often do you encounter CKD in your pregnant patients? Any loss of kidney tissue can adversely affect fetal outcomes, potentially leading to shorter gestational periods. This study found that even without proteinuria, hypertension, or reduced kidney function, loss of kidney tissue is associated with lower birthweight and shorter gestational periods, especially in women with a solitary kidney.
Pregnancy induces a complex array of hemodynamic and physiological changes, affecting circulation to the kidneys, placenta, and fetus. The management of pregnant patients with CKD necessitates a multidisciplinary team, including ‘high-risk’ pregnancy experts. Further studies are needed to investigate and delineate the pathophysiology and mechanisms involved, aiding in the development of adequate management strategies for these individuals.
A Case-based Narrative Review of Pregnancy-associated Atypical Hemolytic Uremic Syndrome/Complement-mediated Thrombotic Microangiopathy
This narrative review provides an insightful overview of atypical hemolytic uremic syndrome (aHUS) as a complement-mediated thrombotic microangiopathy, particularly in the context of pregnancy. The narrative review highlights the complexity of diagnosing aHUS/CM-TMA during pregnancy due to its overlapping symptoms with other thrombotic microangiopathies, such as hypertensive disorders.
The two illustrative cases emphasize the necessity of precise diagnosis for effective management and treatment. The first case demonstrates successful management of aHUS with eculizumab, aided by genetic testing, leading to a positive pregnancy outcome. The second case underscores the challenges of
distinguishing aHUS in the postpartum period, with persistent complement activation despite negative genetic testing. The detailed discussion on diagnostic tests, including placental health, fetal anatomy, and complement activation, effectively underscores the importance of comprehensive evaluation in guiding management. This review highlights the evolving approach to managing pregnancy-associated aHUS/CM-TMA, highlighting the critical role of anticomplement therapy.
Reassuring Pregnancy Outcomes in Women With Mild COL4A3-5–related Disease (Alport Syndrome) and Genetic Type of Disease Can Aid Personalized Counseling
Pregnancy in women with chronic kidney disease (CKD) presents unique challenges, necessitating specialized care and monitoring. CKD can adversely affect pregnancy outcomes, increasing the risk of gestational hypertension, preeclampsia, preterm birth, and low birth weight. For women with Alport Syndrome (AS), these risks vary with the disease’s inheritance patterns: X-linked, autosomal dominant, or autosomal recessive.
The ALPART-network (mAternaL and fetal PregnAncy outcomes of women with AlpoRT syndrome) study indicates that neonatal outcomes for AS are generally favorable, with a 100% live birth rate and a median gestational age of 39 weeks. However, gestational hypertension (23%) and preeclampsia (20%) remain significant concerns. Women with autosomal recessive AS (ARAS) face higher rates of early preterm births and lower birth weights, highlighting the need for tailored care and vigilant monitoring.
This study provides key insights into managing CKD in pregnancy, especially for women with AS. Stratifying outcomes by AS inheritance patterns offers valuable data for refining individualized pre-pregnancy counseling and antenatal care. The finding that pregnancy does not significantly worsen the decline in estimated glomerular filtration rate is reassuring for those with mild AS. However, the risks associated with ARAS stress the importance of early diagnosis and close monitoring. The study’s large sample size and multicenter collaboration enhance the reliability of its conclusions, supporting the integration of disease-specific factors into clinical practice. This research advances our understanding of CKD in pregnancy and underscores the need for personalized care strategies to optimize maternal and fetal outcomes.
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KIDNEY INTERNATIONAL REPORTS ARTICLE |
Researchers at the University of Colorado Hospital conducted an online survey of female patients with CKD to understand their perspectives on family planning. A total of 136 women responded.
While the majority of respondents believed that kidney disease increased their risk of pregnancy complications, they had not discussed with their nephrologist the health risks of a potential pregnancy, their desire to have children, pregnancy prevention, or optimizing their health prior to pregnancy. These results highlight the lack of family planning for women with CKD that needs to be addressed in the clinical setting.
Women Leading and Participating in Nephrology Randomized Clinical Trials: A Meta-epidemiologic Study
Women are underrepresented in leadership and participation in randomized controlled trials (RCTs). The authors used MEDLINE and EMBASE to conduct a bibliometric review of nephrology RCTs over ten years from 2021 to 2022 to investigate trial participation and leadership of women in RCTs. A total of 1770 studies were examined, and 395 RCTs met the eligibility requirements.
The share of women in corresponding, first, and last authorship positions remained consistent at 20% across time (P ¼ 0.94). Male lead authors were statistically less likely to enroll women in RCTs. Female lead authors were less likely to be sponsored by industry (OR: 0.30; 95% CI: 0.14-0.63; P ¼ 0.002) or to lead international trials (OR: 0.11; 95% CI: 0.01-0.83; P ¼ 0.03). Trials with sex-specific eligibility criteria had a higher likelihood of having female leaders (OR: 2.56; 95% CI: 1.19-5.49; P ¼ 0.02) than those without. Gender discrepancies in RCT participation and leadership persist in nephrology and have not improved over time. Strategies to address inequities must be implemented and assessed.
In this study by Reynolds and colleagues, changes in estimated glomerular filtration rate (eGFR) were evaluated in women included in the Cure Glomerulonephropathy study.
The women were classified into three groups: those with a history of complicated pregnancy, those with a history of pregnancy without complications, and those with no history of pregnancy. The fact that women with a history of complicated pregnancies exhibit a more significant decline in eGFR than those with uncomplicated or no pregnancies is critical. It suggests that pregnancy complications, particularly preeclampsia and related conditions, have a lasting impact on kidney function.
This article highlights a significant gap in reproductive counseling for women with chronic kidney disease (CKD). Despite the increased risk of adverse pregnancy outcomes for this population, nephrologists infrequently address reproductive health, leaving patients feeling disempowered. The study’s qualitative interviews with patients and nephrologists from a single academic medical center revealed that patients expressed a desire for nephrologists to initiate discussions about reproductive health, which are currently not systematically done.
Both patients and nephrologists agree that risk communication needs improvement but differ in their focus—nephrologists emphasize individualized risk estimates, while patients seek a balance of risks, benefits, and management strategies. The findings highlight the necessity for more dialogue about reproductive health in kidney care and suggest that developing patient-centered counseling tools could bridge the communication gap, ultimately improving reproductive health outcomes for women with CKD.
The experiences and information needed for reproductive health counseling among women with chronic kidney disease (CKD) are poorly defined despite the established importance of pregnancy planning in this higher-risk demographic. Australian adult women with CKD, as well as their partners or family members, participated in a consumer-designed survey to discuss their experiences and preferences for pregnancy-related counseling, support, and education.
In this study, pregnancy-related discussions were initiated mainly by women themselves. The majority of women (86.4%) preferred counseling from nephrologists and in-person settings (79.6%) rather than websites, handouts, or online support groups. Great-quality, multiformat information from topic specialists, peer aid, and psychological support were all in great demand.
The study revealed that preconception counseling and information needs of women living with CKD are currently unmet. Frameworks and approaches to assist patients and clinicians, particularly nephrologists, in initiating and carrying out sensitive, helpful, and informed shared decision-making regarding pregnancy are critically needed.