Contraception for All Conceivable Occasions: The CKD Care Gap

Related article, 100738 Related article, 100738 Is the nephrologist responsible for providing contraceptive counseling to their female patients? A strong argument for the affirmative is presented through the inherent relationship between chronic kidney disease (CKD) and reproductive health. First, although impaired fertility is believed to be common in CKD and is likely proportional to the degree of abnormal kidney function, pregnancy continues to occur in every stage of CKD. In fact, pregnancy rates appear to be increasing among people receiving kidney replacement therapy,1Hewawasam E. Davies C.E. Gulyani A. et al.Factors influencing fertility rates in Australian women receiving kidney replacement therapy: analysis of linked Australia and New Zealand Dialysis and Transplant Registry and perinatal data over 22 years.Nephrol Dial Transplant. 2022; 37: 1152-1161https://doi.org/10.1093/ndt/gfab157Crossref PubMed Scopus (9) Google Scholar although up to 30% of pregnancies in the kidney transplant population are unplanned.2Bramham K. Nelson-Piercy C. Gao H. et al.Pregnancy in renal transplant recipients: a UK national cohort study.Clin J Am Soc Nephrol. 2013; 8: 290-298https://doi.org/10.2215/CJN.06170612Crossref PubMed Scopus (154) Google Scholar Pregnancy in the setting of CKD imparts increased risk to both the individual and the fetus and needs to be managed carefully, including in the pre- and postnatal periods, by a multidisciplinary team to optimize outcomes.3Wiles K. Chappell L. Clark K. et al.Clinical practice guideline on pregnancy and renal disease.BMC Nephrol. 2019; 20: 401https://doi.org/10.1186/s12882-019-1560-2Crossref PubMed Scopus (100) Google Scholar Second, the timing of pregnancy related to important CKD-specific events, such as active glomerulonephritis, dialysis, and kidney transplantation, is a critical component in safe perinatal planning and management.3Wiles K. Chappell L. Clark K. et al.Clinical practice guideline on pregnancy and renal disease.BMC Nephrol. 2019; 20: 401https://doi.org/10.1186/s12882-019-1560-2Crossref PubMed Scopus (100) Google Scholar As such, individuals with CKD with unplanned pregnancies living in jurisdictions with restricted or banned access to pregnancy termination services can face impossible choices given not only the significant kidney risk, but also the risk to survival, with continued gestation. Third, in addition to the complex interplay between CKD and pregnancy, medications frequently used to manage CKD are commonly teratogenic (eg, angiotensin-converting enzyme inhibitors and mycophenolate mofetil) or have not been studied in the setting of pregnancy or lactation (eg, sodium/glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonists). Prescribers of these medications, including nephrologists, have a responsibility to not only disclose the reproductive implications of these medications but also provide concurrent access to effective contraception. Finally, menstrual abnormalities, including heavy menstrual bleeding, are common in CKD4Chang D.H. Dumanski S.M. Brennand E.A. et al.Female reproductive health and contraception use in CKD: an international mixed-methods study.Kidney Med. 2023; 5100713https://doi.org/10.1016/j.xkme.2023.100713Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,5Rytz C.L. Kochaksaraei G.S. Skeith L. et al.Menstrual abnormalities and reproductive lifespan in females with CKD: a systematic review and meta-analysis.Clin J Am Soc Nephrol. 2022; 17: 1742-1753https://doi.org/10.2215/CJN.07100622Crossref PubMed Scopus (8) Google Scholar and can be managed with hormonal contraception. In fact, management of menstruation is reported to be the reason for contraceptive use by nearly half of female individuals living with CKD.4Chang D.H. Dumanski S.M. Brennand E.A. et al.Female reproductive health and contraception use in CKD: an international mixed-methods study.Kidney Med. 2023; 5100713https://doi.org/10.1016/j.xkme.2023.100713Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar However, despite these arguably higher needs for contraception—that must be in accordance with a person’s values and wishes—contraceptive use is paradoxically extremely low in the CKD population.6Shah S. Christianson A.L. Thakar C.V. Kramer S. Meganathan K. Leonard A.C. Contraceptive use among women with end-stage kidney disease on dialysis in the United States.Kidney Med. 2020; 2: 707-715.e1https://doi.org/10.1016/j.xkme.2020.08.010Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,7Shah S. Christianson A.L. Bumb S. Verma P. Contraceptive use among women with kidney transplants in the United States.J Nephrol. 2022; 35: 629-638https://doi.org/10.1007/s40620-021-01181-0Crossref PubMed Scopus (7) Google Scholar Female individuals with CKD face challenging life decisions about pregnancy and parenthood, which can lead to emotional turmoil that includes decisional conflict, feelings of failure, fear, and grief.8Tong A. Jesudason S. Craig J.C. Winkelmayer W.C. Perspectives on pregnancy in women with chronic kidney disease: systematic review of qualitative studies.Nephrol Dial Transplant. 2015; 30: 652-661https://doi.org/10.1093/ndt/gfu378Crossref PubMed Scopus (69) Google Scholar Considering that many people with CKD, particularly in the advanced stages, view their nephrologist to be their primary care provider,9Holley J.L. Nephrologists as primary care providers: a review of the issues.Am J Kidney Dis. 1998; 31: 574-583https://doi.org/10.1053/ajkd.1998.v31.pm9531172Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar the question has arisen: what is the role of the nephrologist in the reproductive care of the female patient with CKD? In this issue of Kidney Medicine, Shah et al10Shah S. Katz-Greenberg G. Gudsoorkar P. et al.Contraceptive use in females with advanced CKD: a qualitative study.Kidney Med. 2023; 5100738https://doi.org/10.1016/j.xkme.2023.100738Abstract Full Text Full Text PDF Scopus (1) Google Scholar qualitatively describe perspectives of female patients with CKD on contraception in an American single center-based cohort study. Through focus group interviews with 16 adult female patients with CKD (nondialysis-or-transplant CKD, CKD treated with dialysis, and CKD treated with kidney transplant), the authors identified 5 main themes: limited knowledge regarding reproductive health in CKD, inadequate counseling on contraceptive use, lack of interdisciplinary coordination regarding contraceptive use, insufficient educational resources available to guide contraceptive discussions, and a need for further research to better understand reproductive needs of the population living with CKD. The results from this study suggest that not only do female individuals with CKD experience frustration with the perceived lack of knowledge by their nephrologists and delay in provision of information regarding reproductive health, but some participants also voiced concerns over not being offered or even being denied access to contraception, which participants felt was further exacerbated by a lack of multidisciplinary communication between providers such as gynecologists and nephrologists. To address these gaps, the authors outlined a clinical action plan that targets increased efficacy of contraceptive counseling, improved multidisciplinary care and physician-patient communication, and implementation of patient support groups and physician training. The study by Shah et al10Shah S. Katz-Greenberg G. Gudsoorkar P. et al.Contraceptive use in females with advanced CKD: a qualitative study.Kidney Med. 2023; 5100738https://doi.org/10.1016/j.xkme.2023.100738Abstract Full Text Full Text PDF Scopus (1) Google Scholar is a critical addition to the existing literature, especially in the context of the increasing focus on person-centered kidney care in this era of precision health. Although limited by a small sample size and single-site recruitment, previous studies have mainly explored contraceptive use in female individuals with CKD using administrative data-based approaches, with few including qualitative methodology, highlighting the novelty of this work. In a retrospective cohort study of 35,732 women aged 15-44 years receiving dialysis in the United States from 2005-2014, the rate of contraceptive use was only 5.3%, with intrauterine devices and oral contraceptive pills being the most common methods of contraception.6Shah S. Christianson A.L. Thakar C.V. Kramer S. Meganathan K. Leonard A.C. Contraceptive use among women with end-stage kidney disease on dialysis in the United States.Kidney Med. 2020; 2: 707-715.e1https://doi.org/10.1016/j.xkme.2020.08.010Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Similarly, a US retrospective cohort of 13,150 women with kidney transplants, representing 26,624 person-years, reported a rate of contraceptive use of 9.5%.7Shah S. Christianson A.L. Bumb S. Verma P. Contraceptive use among women with kidney transplants in the United States.J Nephrol. 2022; 35: 629-638https://doi.org/10.1007/s40620-021-01181-0Crossref PubMed Scopus (7) Google Scholar Recognizing these administrative data-based studies would not have captured if participants were sexually active, nonprescription contraceptive use (eg, condoms), or the presence of conditions that can be treated with hormonal contraception (eg, acne, heavy menstrual bleeding, etc), contraceptive use in the female population with CKD is markedly below that of the age-matched US general population.11Daniels K. Abma J.C. Current contraceptive status among women aged 15–49: United States, 2015–2017. NCHS Data Brief, No. 327.December 2018https://www.cdc.gov/nchs/data/databriefs/db327-h.pdfDate accessed: September 7, 2023Google Scholar Although previous studies have reported infrequent contraceptive counseling by nephrologists or other health care providers,12Hendren E.M. Reynolds M.L. Mariani L.H. et al.Confidence in women’s health: a cross border survey of adult nephrologists.J Clin Med. 2019; 8: 176https://doi.org/10.3390/jcm8020176Crossref PubMed Scopus (31) Google Scholar, 13Ramesh S. James M.T. Holroyd-Leduc J.M. et al.Sex hormone status in women with chronic kidney disease: survey of nephrologists’ and renal allied health care providers’ perceptions.Can J Kidney Health Dis. 2017; 42054358117734534https://doi.org/10.1177/2054358117734534Crossref PubMed Scopus (18) Google Scholar, 14Vasylyeva T.L. Page-Hefley S. Almaani S. et al.Evaluation of the reproductive care provided to adolescent patients in nephrology clinics: a Pediatric Nephrology Research Consortium study.Kidney Int Rep. 2021; 6: 1411-1415https://doi.org/10.1016/j.ekir.2021.02.007Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar the results of the study by Shah et al10Shah S. Katz-Greenberg G. Gudsoorkar P. et al.Contraceptive use in females with advanced CKD: a qualitative study.Kidney Med. 2023; 5100738https://doi.org/10.1016/j.xkme.2023.100738Abstract Full Text Full Text PDF Scopus (1) Google Scholar provide important insights from a patient perspective as to why rates of contraceptive use in the CKD population are so low. Although this study was limited to the US population, a recent international mixed-methods study reported similar results,4Chang D.H. Dumanski S.M. Brennand E.A. et al.Female reproductive health and contraception use in CKD: an international mixed-methods study.Kidney Med. 2023; 5100713https://doi.org/10.1016/j.xkme.2023.100713Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar specifically low levels of contraception use that were commonly reported to be related to fear as well as a desire for greater multidisciplinary care and communication among nephrology and other health care providers, a finding echoed in other qualitative studies of female individuals with CKD.15Beanlands H. McCay E. Pahati S. Hladunewich M.A. Through the lens of chronic kidney disease: a qualitative study of the experiences of young women living with CKD.Can J Kidney Health Dis. 2020; 72054358120945475https://doi.org/10.1177/2054358120945475Crossref PubMed Scopus (6) Google Scholar These concerns are supported by the literature: North American nephrologists following adults reported providing contraception or preconception counseling to fewer than one woman per month, with almost two-thirds of nephrologists reporting a lack of confidence in women’s health issues, including menstrual disorders, preconception counseling, and pregnancy management.12Hendren E.M. Reynolds M.L. Mariani L.H. et al.Confidence in women’s health: a cross border survey of adult nephrologists.J Clin Med. 2019; 8: 176https://doi.org/10.3390/jcm8020176Crossref PubMed Scopus (31) Google Scholar Although pediatric nephrologists in the United States report greater overall comfort with contraceptive counseling of patients with CKD, this comfort may be largely limited to barrier methods.14Vasylyeva T.L. Page-Hefley S. Almaani S. et al.Evaluation of the reproductive care provided to adolescent patients in nephrology clinics: a Pediatric Nephrology Research Consortium study.Kidney Int Rep. 2021; 6: 1411-1415https://doi.org/10.1016/j.ekir.2021.02.007Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Given that female reproductive health is a normal part of the life cycle, this apprehension around contraceptive counseling is somewhat surprising, particularly given the complexity of the typical patient in nephrology practice.16Tonelli M. Wiebe N. Manns B.J. et al.Comparison of the complexity of patients seen by different medical subspecialists in a universal health care system.JAMA Netw Open. 2018; 1e184852https://doi.org/10.1001/jamanetworkopen.2018.4852Crossref PubMed Scopus (158) Google Scholar Although maternal and neonatal adverse outcomes are common in pregnancy in the setting of CKD, shared decision making is only achievable if that risk is appreciated and communicated effectively. Underscoring the importance of discussing female reproductive health in CKD care, a cross-sectional assessment of 179 women with CKD attending a prepregnancy counseling clinic reported a positive experience.17Wiles K.S. Bramham K. Vais A. et al.Pre-pregnancy counselling for women with chronic kidney disease: a retrospective analysis of nine years’ experience.BMC Nephrol. 2015; 16: 28https://doi.org/10.1186/s12882-015-0024-6Crossref PubMed Scopus (56) Google Scholar In contrast, 15% of female kidney transplant recipients reported unwanted pregnancies due to a lack of contraceptive use combined with poor understanding about their reproductive potential after transplantation.18Xu L. Yang Y. Shi J.G. et al.Unwanted pregnancy among Chinese renal transplant recipients.Eur J Contracept Reprod Health Care. 2011; 16: 270-276https://doi.org/10.3109/13625187.2011.589920Crossref PubMed Scopus (24) Google Scholar Participants in the study by Shah et al10Shah S. Katz-Greenberg G. Gudsoorkar P. et al.Contraceptive use in females with advanced CKD: a qualitative study.Kidney Med. 2023; 5100738https://doi.org/10.1016/j.xkme.2023.100738Abstract Full Text Full Text PDF Scopus (1) Google Scholar highlighted that they were unsure how hormonal contraceptives would interact with their other medications or their CKD/kidney health, a finding echoed in another recent study of female individuals living with CKD in which participants cited fear of the potential effects of contraception.4Chang D.H. Dumanski S.M. Brennand E.A. et al.Female reproductive health and contraception use in CKD: an international mixed-methods study.Kidney Med. 2023; 5100713https://doi.org/10.1016/j.xkme.2023.100713Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The impact of contraception on nonreproductive physiology and function is not well studied in any population, let alone persons with CKD, although a recent systematic review suggests differential effects of various hormonal contraceptive methods on blood pressure,19Kalenga C.Z. Dumanski S.M. Metcalfe A. et al.The effect of non-oral hormonal contraceptives on hypertension and blood pressure: a systematic review and meta-analysis.Physiol Rep. 2022; 10e15267https://doi.org/10.14814/phy2.15267Crossref Scopus (5) Google Scholar which may have implications for kidney health and disease. Although contraceptive use is commonly an inclusion requirement in randomized controlled trials of medications prescribed in nephrology, it is rarely a variable that is considered in analysis or presentation of results. Using the knowledge that is available, clinical practice statements and guidelines have been developed by experts to guide nephrologists in contraceptive counseling,3Wiles K. Chappell L. Clark K. et al.Clinical practice guideline on pregnancy and renal disease.BMC Nephrol. 2019; 20: 401https://doi.org/10.1186/s12882-019-1560-2Crossref PubMed Scopus (100) Google Scholar,20Attini R. Cabiddu G. Montersino B. et al.Contraception in chronic kidney disease: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology.J Nephrol. 2020; 33: 1343-1359https://doi.org/10.1007/s40620-020-00717-0Crossref PubMed Scopus (13) Google Scholar although the uptake of informed contraceptive counseling practices in nephrology has not yet been evaluated. Although the majority of contraceptives are designed for use by female individuals, it is imperative to highlight that contraception and the consequences of unprotected sex are key issues for health care providers to discuss with all persons with CKD. There is an urgent and unmet need for a multidisciplinary approach to reproductive health and contraceptive counseling that, to date, has been largely neglected in the CKD population, and, truth be told, in medicine in general. As outlined by the World Health Organization, “contraceptive information and services are fundamental to the health and human rights of all individuals.” Although accessible, safe, and effective contraception is necessary for all, the consequences of an unplanned pregnancy are exacerbated in the setting of CKD. The study by Shah et al10Shah S. Katz-Greenberg G. Gudsoorkar P. et al.Contraceptive use in females with advanced CKD: a qualitative study.Kidney Med. 2023; 5100738https://doi.org/10.1016/j.xkme.2023.100738Abstract Full Text Full Text PDF Scopus (1) Google Scholar adds to the increasingly unambiguous data highlighting this patient-identified unmet need in the care of persons living with CKD. How can we even ask the question if the nephrologist is responsible for providing contraceptive counseling to their female patients? The answer is yes, they unequivocally are. Chantal L. Rytz, MSc, Sandra M. Dumanski, MD, MSc, and Sofia B. Ahmed, MD, MMSc. CLR is supported by a doctoral scholarship from the Canadian Institutes of Health Research. The authors declare that they have no relevant financial interests. Received September 11, 2023 in response to an invitation from the journal. Accepted September 28, 2023 after editorial review by the Editor-in-Chief. Contraceptive Use in Females With Advanced CKD: A Qualitative StudyKidney MedicineVol. 5Issue 12PreviewPregnancy in females with kidney disease is not uncommon and is associated with adverse maternal and fetal outcomes. The use of contraception in females with chronic kidney disease remains low. We sought to describe the perspectives of female patients with advanced chronic kidney disease on the use of contraception. Full-Text PDF Open Access

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