Pregnancy and Kidney Disease

Upskilling Kidney Health Professionals

Pregnancy and Kidney Disease Toolkit

Women with chronic kidney disease (CKD) face unique challenges when it comes to fertility, preconception counselling, pregnancy care, as well as postpartum management and follow-up. Pregnancy can be an important window into future kidney and cardiovascular health and represents an important opportunity for the detection and diagnosis of kidney conditions. In many regions, pregnancy-related kidney morbidity remains alarmingly high, reflecting major inequities in women’s health care. Limited guidance on managing these often complex cases leads to inconsistent care and, in some cases, poor outcomes for both mother and baby.

With the increasing prevalence of CKD, this toolkit is essential to ensure that clinicians worldwide are prepared to meet the growing demand for expert care in this complex field. BUT…studies confirm many clinicians fear this area, feel they do not have the necessary training and skills, or are uncomfortable raising pregnancy with patients. There is an urgent need to grow obstetric nephrology expertise globally.

Purpose of the Toolkit

This Toolkit aims to provide evidence-based educational materials. This toolkit is designed for nephrologists and health professionals wishing to increase their own knowledge, as well as to teach others effectively on these topics. Whether you are delivering a lecture to peers, training residents, or educating multidisciplinary teams, these resources are adaptable to various settings and audiences.

By equipping nephrologists with the tools needed to understand, manage, and treat women with CKD who are planning to conceive or pregnant, we aim to improve maternal and fetal outcomes and advance care on a global scale. By using and sharing this toolkit, we hope to inspire more clinicians to become champions of obstetric nephrology.

Toolkit development

This toolkit was developed by the Faculty and Trainers of the ISN Train the Trainer Program for Pregnancy and Kidney Disease, led by Shilpanjali Jesudason (Australia) and Michelle Hladunewich (Canada). More information on the Train the trainer program can be found here

ISN TTT Preconception counselling basics (January 2025)
Podcast: ISN Train the Trainer Program for Pregnancy and Kidney Disease

FACULTY 2023-4

Co-leads – Shilpanjali Jesudason, Australia and Michelle Hladunewich, Canada

  • Angela Makris, Australia
  • Dominique Martin, Australia
  • Liz Lightstone, UK
  • Kate Wiles, UK
  • Kate Bramham, UK
  • Alejandra Orozco Guillen, Mexico
  • Giorgina Piccoli, Italy/France
  • Valerie Luyckx, Switzerland

TRAINERS 2023-4

  • Rasha Samir, Egypt
  • Ghada Ankawi, Saudi Arabia
  • Andrea Oliverio, USA
  • Nishanta Tangirala, Australia
  • Tamara Glavinovic, Canada
  • Divya Bajpai; India
  • Kenneth Kapembwa, Zambia
  • Bala Waziri, Nigeria
  • Iara Da Silva, Spain
  • Priscilla Smith, UK

Overview

  1. Fertility and Kidney Disease
    1. Assessing Fertility in women with CKD – clinical history and basic investigations
    2. Sexual dysfunction in women with CKD
    3. Fertility and cyclophosphamide
  2. Assisted Reproductive Technologies
    1. Fertility preservation options in women with CKD
    2. Assisted reproduction options
    3. Preimplantation Genetic Testing
  3.  Contraception management in Women with CKD
    1. Purpose and benefits of contraception
    2. Safe contraceptive options for women with CKD
    3. Risks associated with hormonal contraceptives in CKD
  4. Counselling for unplanned pregnancy
    1. Options for safe termination of pregnancy in CKD
  1. Approach to Preconception Counselling
    1. Frameworks for counselling
    2. Ethical considerations in counselling
    3. Assessing reproductive goals and undertaking shared decision-making
  2. Preparing for pregnancy
    1. Overview of risk stratification and management principles
    2. Explaining risks to patients
  1. Epidemiology of CKD and pregnancy
  2. Renal Physiological changes in pregnancy
  3. Outcomes of pregnancy and CKD
    1. Maternal and fetal outcomes
    2. Impact of Pregnancy on renal outcomes
    3. Prognostic factors for successful pregnancy
  1. Managing Pregnancy in CKD
    1. Monitoring kidney function, blood pressure and proteinuria
  1. Impact of diabetes on pregnancy
  2. Managing diabetes in pregnancy
  3. Impact of pregnancy on diabetes complications and diabetic kidney disease
  1. Preconception Counselling in Lupus Nephritis / GN
  2. Optimizing Lupus Nephritis / GN control before conception
    1. Assessing Lupus Nephritis / GN activity and renal reserve
    2. Management of immunosuppressive and antiproteinuric therapies
  1. Pregnancy Outcomes in Lupus Nephritis / GN
    1. Maternal and fetal outcomes
    2. Risk and Impact of Lupus Nephritis / GN flares
  1. Managing Lupus Nephritis / GN During Pregnancy
    1. De novo disease in pregnancy
    2. Renal Biopsy in Pregnancy
    3. Managing disease flares – differentiating from pre-eclampsia
    4. Managing Nephrotic Syndrome in Pregnancy
    5. Anticoagulation management in pregnancy
    6. Post-partum management
  1. Epidemiology of pregnancy in dialysis recipients (haemodialysis and peritoneal dialysis)
  2. Preconception Counselling for patients with advanced CKD and receiving dialysis
  3. Pregnancy Outcomes in women receiving dialysis
  4. Managing Dialysis in Pregnancy
    1. Dialysis regimens and adjustments during pregnancy – hemodialysis and peritoneal dialysis
    2. Residual kidney function and dialysis intensity in pregnancy
    3. Fluid management in dialysis recipients during pregnancy
    4. Managing Nutrition, Anemia and Bone / Mineral Metabolism in dialysis recipients during pregnancy
    5. Managing Dialysis Access in pregnancy
    6. Home dialysis and pregnancy
  5. Post-partum management
  6. Ethical issues – dialysis resourcing
  1. Kidney allograft Accommodation to pregnancy
  2. Fertility post-transplantation
    1. Epidemiology of pregnancy post-kidney transplant – birth rates
  3. Risks and outcomes of pregnancy post-transplant
  4. Preconception Counselling in Transplant Recipients
    1. General approaches and concepts
    2. Ethical considerations in pregnancy counselling
  5. Contraception post-kidney transplant
  6. Risk factors for adverse pregnancy outcomes
    1. Stratifying risk and preparing for pregnancy
  1. Pregnancy Outcomes in Kidney Transplant Recipients
    1. Maternal and Fetal outcomes
    2. Graft function and Graft loss during and after pregnancy
  1. Pregnancy management in Kidney transplant recipients
    1. Immunosuppressive Management in Pregnancy
    2. Evaluating graft dysfunction in pregnancy
    3. Infections during pregnancy – CMV and UTI
  1. Epidemiology of PR-AKI – global perspective
    1. Definitions and Diagnostic challenges for PR-AKI
  2. Aetiology of Pregnancy-Related AKI and risk factors
  3. Maternal and Fetal Outcomes of PR-AKI
  4. Risk Assessment for PR-AKI – antenatal and peri-partum
  5. Management of PR-AKI
    1. Supportive management – general approaches
    2. Treatment of specific causes
    3. Indications for dialysis
    4. Indications for therapeutic plasma exchange
  6. Longer term sequelae after PR-AKI and follow up
  1. Definitions of hypertensive disorders of pregnancy
    1. Diagnostic Criteria for Preeclampsia
  2. Pathophysiology of Preeclampsia and Placental dysfunction
  3. Epidemiology of pre-eclampsia across the globe
    1. Risk factors for preeclampsia in CKD
  1. Pre-eclampsia and maternal / fetal outcomes
  2. Angiogenic biomarkers in pre-eclampsia and CKD
  3. Clinical features of Pre-eclampsia
    1. Renal involvement in pre-eclampsia
    2. Differential diagnosis of pre-eclampsia in CKD
  1. Management of Preeclampsia in CKD
    1. Pre-eclampsia prevention
    2. Antihypertensive therapy and blood pressure targets
    3. Role of magnesium sulfate in severe preeclampsia
    4. Timing and mode of delivery in preeclampsia
  1. Postpartum Management including long-term follow-up
  1. The post-natal period and early post partum care
    1. Recovery of kidney function, breastfeeding, contraception
    2. Neonatal wellbeing and nephrogenesis
  1. Short-medium term followup
    1. Blood pressure, diabetes, weight management, psychological, nutrition, medication management
    2. Infant development
  1. Long-term Follow-up
    1. Cardiovascular and Renal Risks for mothers
    2. Follow-up after PR-AKI
    3. Preterm or complicated birth and long term outcomes for infants
    4. Future pregnancy planning

Accessing the Toolkit

The toolkit materials are accessible via the ISN Academy Portal, here.

You will need to register to access the materials. This is important as it helps us track how the materials are being used.

When you access content, you will be asked to complete a short survey about yourself and how you intend to use these materials. You will be contacted later to complete a short survey on how the materials were used and any feedback. The ISN keeps this information confidential.

This data is critically important for us to under stand how to develop the Toolkit in the future!

How to Use this Toolkit

The toolkit consists of a series of modules (PowerPoint slide sets), each accompanied by speaker notes, references, and additional reading materials. These slide sets are meant to be flexible, allowing trainers to customize them based on their audience, clinical settings, or regional guidelines. The slides can also be used for self-directed learning.

At the beginning of each module, there are introductory slides explaining how to use the content in teaching others.

  1. Review the Content: Begin by familiarizing yourself with the slide set and notes. The notes will guide you on how to present each slide effectively.
  2. Adapt to Your Audience: While the slides provide a comprehensive overview, they can be adapted to meet the specific needs of your audience. For instance, you might add case studies from your region, or tailor the content to address local practices or guidelines.
  3. Prepare for Discussion: Each module encourages interactive teaching. As a trainer, be prepared to engage with your audience by asking questions, leading discussions, or facilitating case-based learning.
  4. Prepare for Evaluation: Each module has learning objectives and MCQs for post-education evaluation.
ISN TTT Pregnancy and CKD Education Principles (December 2024)