Women with health issues and CKD face complex challenges
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Women who are pregnant and have preeclampsia worry nephrologists like Nityasree Srialluri, MD, MS, because without early detection chronic kidney disease may not be far behind.
“The early detection of preeclampsia has the potential of lowering CKD and cardiovascular risk,” Srialluri, with the division of nephrology in the department of medicine at Johns Hopkins School of Medicine in Baltimore, told Healio | Nephrology News & Issues. “Better monitoring of these patients could be an important step to reducing morbidity and mortality. Early primary prevention strategies offer better health education, and an opportunity for closer monitoring pre-delivery, during and post-delivery.”
Source: Nityasree Srialluri, MD
Srialluri and colleagues reviewed the cases of 27,800 women with deliveries in the Geisinger Health System between 1996 and 2019. Results showed preeclampsia during the pregnancy created a significant risk for a woman to develop morbidities associated with CKD.
“Preeclampsia is a significant contributor to perinatal and maternal morbidity and is marked by new-onset hypertension and end-organ damage, including acute kidney injury or proteinuria,” Srialluri and colleagues wrote in the American Journal of Kidney Diseases.
The researchers wanted to understand the long-term effects of the disease on kidney function and compared adults with deliveries complicated by preeclampsia to those without in the Geisinger Health System. They found pregnant individuals with preeclampsia “are at a heightened risk for future hypertension, reduced eGFR, and albuminuria, with overall low rates of post-partum testing among both individuals with and without preeclampsia,” they wrote. “These findings underscore the need to consider preeclampsia as an important risk factor for the development of chronic kidney disease. Further studies are required to determine optimal post-preeclampsia monitoring strategies.”
Srialluri told Healio | Nephrology News & Issues that pregnancy and preeclampsia together create the risk of developing CKD, and patients with existing CKD are at higher risk for complications if they have preeclampsia during pregnancy. “There are greater concerns among women with CKD as these women have a higher risk of preeclampsia, and preeclampsia by itself has the risk of progression of underlying CKD.
“Diagnosis of superimposed preeclampsia on CKD is difficult to establish due to the common features shared by CKD and preeclampsia. We know that women are at increased risk of proteinuria and CKD progression during and immediately post pregnancy but studies evaluating longer term outcomes in CKD patients are limited,” Srialluri said.
During the study period, 2,977 of the women with deliveries had at least one pregnancy complicated by preeclampsia, the authors wrote. “ ... In the first 6 months after delivery, 31% vs. 14% of individuals with and without preeclampsia had serum creatinine tests, respectively, and testing for urine protein was the same in both groups, with only 26% having follow-up testing.”
Preeclampsia usually begins after 20 weeks, according to the medical literature, and includes high blood pressure and proteinuria or other signs of organ damage. It can also lead to serious or fatal complications.
New test
In May, the FDA granted marketing authorization to a new test that can help clinicians identify certain women who are pregnant and at high risk for preeclampsia. Called the B·R·A·H·M·S sFlt-1/ PlGF KRYPTOR Test System (Thermo Fisher Scientific), it is an automated immunofluorescent assay that “uses time-resolved amplified cryptate emission technology for the quantitative detection of placental biomarkers, placental growth factor and soluble Fms-like tyrosine kinase-1 in human serum and plasma,” the FDA announced in an update on new product approvals. “According to the CDC, preeclampsia is one of the leading causes of maternal morbidity and is estimated to occur in 3% to 7% of all pregnancies,” according to the FDA update.
Anna Burgner, MD, MEHP, 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, told Healio | Nephrology News & Issues the new test will “undoubtably be beneficial in patients with CKD where it has always been difficult to know if they are developing preeclampsia or if the worsening blood pressure and proteinuria represent a flare of their underlying disease.”
Preclampisa “is the leading cause of maternal death worldwide and increases the risks of a woman developing cardiovascular disease and end-stage kidney disease,” Burgner said.
Complicated management
Women with CKD who are in childbearing years and wish to become pregnant or older women facing issues like menopause can also face higher risks. Duo Qian, MD, and colleagues from the division of internal medicine in the department of nephrology at Tongji Hospital in Wuhan, China, reviewed 4,945 post-menopausal women from the database of the National Health and Nutrition Examination Survey from 1999 to 2014 who faced early menopause. “Compared with women with natural menopause at age [greater than or equal to] 45 [years], women experiencing early natural menopause had a higher risk of CKD,” the authors wrote. “Similarly, as compared to women with surgical menopause at age [greater than or equal to] 45 [years], women in the early surgical menopause group were more likely to have CKD.”
Professional support
Understanding the cross section of women’s health issues and kidney disease is a challenge – even more so because many nephrologists are not comfortable talking about them with patients, Elizabeth Hendren, MD, and colleagues wrote in the Journal of Clinical Medicine.
The researchers reviewing results of a survey showing that a high percentage of nephrologists were not comfortable with discussing health issues brought up by women who were being treated for kidney disease. Most nephrologists averaged once-a-month visits that involved counseling a woman on contraception or preconception.
“Participants lacked confidence in both counseling and managing women’s health,” Hendren, at the time with the division of nephrology in the department of medicine at Sunnybrook Health Sciences Center at the University of Toronto, and colleagues wrote. “Failure to review a woman’s obstetric history can diminish the quality of a providers’ risk assessment, both for future pregnancy adverse outcomes, as well as for future chronic disease development,” Hendren and colleagues wrote.
The survey results also showed there was a lack of training among nephrologists in counseling women regarding health issues. “... [O]ver half of all respondents reported that lack of training in women’s health limited their ability to counsel and manage specific issues, echoing findings from a recent national U.S. survey assessing self-perceived training adequacy among recently graduated nephrology fellows, which reported that 45.9% of respondents answered they had ‘some training, but not enough to feel confident’ in renal complications of pregnancy,” they wrote.
In that study, which was published in the Clinical Journal of the American Society of Nephrology, Jeffrey Berns, MD, and colleagues wrote that a “significant percentage of respondents” to the survey reported little or no training on pregnancy complications. “Many of these areas were also identified as somewhat or very important to the careers and practices of respondents,” the authors wrote.
“[O]ur study identifies low frequencies of counseling and low confidence across the spectrum of women’s health,” Hendren and colleagues wrote. “As a broad range of women’s health issues are highly relevant to kidney disease, increased attention to these issues is required to help nephrologists provide patient-centered and disease-specific care.”
Siralluri said there is a long-term risk of poor management of women’s health issues. The results from the study of patients in the Geisinger Health System are concerning, she said, “especially with rising rates of obesity and higher maternal age. Women are now more than ever at risk for preeclampsia especially those with underlying CKD.”
KDIGO guidelines
The Kidney Disease: Improving Global Outcomes (KDIGO) recently held a controversies conference on women’s health issues and nephrology. The 4-day meeting was “a step toward improving knowledge and ability to help women with and at risk for chronic kidney disease around the world,” wrote authors Giorgina Piccoli, MD, and Christina Wyatt, MD, in a recent summary of the meeting.
More than 75 experts from more than 30 countries attended the conference, which included adult and pediatric nephrologists, epidemiologists, obstetricians, gynecologists, neonatologists, dietitians, midwives and patients.
Piccoli, an associate professor in nephrology at University of Angers, France, and Wyatt, an associate professor of medicine and nephrology at Duke Health and a member of the Duke Clinical Research Institute, participated in discussions at the conference on sex and gender disparities in kidney care and access to services. Conference attendees also debated best practices for reproductive health and pregnancy complications in women with CKD. “This population may have reduced fertility, early menopause, alterations in body image and reduction in sexual desire and satisfaction,” Piccoli and Wyatt wrote in a recent issue of Healio | Nephrology News & Issues. “Pregnant women with CKD, even at early stages, have an increased risk for early delivery and developing hypertensive disorders of pregnancy.”
The KDIGO work group expects to have a full report out early next year.
- References:
- Berns J, et al. Clin J Am Soc Nephrol. 2010:doi:10.2215/CJN.08461109.
- FDA round-up. https://www.fda.gov/news-events/press-announcements/fda-roundup-may-19-2023.
- https://www.healio.com/news/nephrology/20230808/kdigo-looks-at-important-issues-for-women-and-kidney-health
- Newly approved blood test can help predict severe preeclampsia diagnoses earlier and more accurately. https://www.uchicagomedicine.org/forefront/womens-health-articles/newly-approved-blood-test-can-help-predict-severe-preeclampsia-diagnoses-earlier-and-more-accurately. Published June 12, 2023. Accessed Aug. 18, 2023.
- Qian, D, et al. Front Med. 2022;doi:10.3389/fmed.2022.823835.
- Srialluri N, et al. Am Jrnl Kid Dis.2023;doi:10.1053/j.ajkd.2023.04.010.
- For more information:
- Anna Burgner, MD, MEHP, can be reached at anna.burgner@vumc.org.
- Elizabeth Hendren, MD, can be reached at ehendren@providencehealth.bc.ca.
- Nityasree Srialluri, MD, MS, can be reached at nsriall1@jh.edu.
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