Women and Kidney Disease: Reflections on World Kidney Day 2018

Kidney Health and Women's Health: A Case for Optimizing Outcomes for Present and Future Generations

Giorgina B. Piccoli; Mona Alrukhaimi; Zhi-Hong Liu; Elena Zakharova; Adeera Levin

Disclosures

Nephrol Dial Transplant. 2018;33(2):189-193. 

In This Article

Present and Future: What We Do Not Know

Pregnancy, AKI, autoimmune diseases, CKD, dialysis and transplantation present specific challenges for women for which many unanswered questions persist.

In high-income countries with increasing maternal age and assisted fertilization, there may be an increase in PE that may impact future generations if associated with adverse fetal outcomes. The increase in in vitro fertilization techniques for those of advanced maternal age may lead to multiple pregnancies, which may predispose to PE, intrauterine growth restriction or both. It is unknown whether this will lead to an increase in CKD and CVD in women and impact their offspring in the future?

How should we define the preconception risks of pregnancy with respect to current proteinuria cutoffs? Indications on when to start dialysis in pregnancy are not well established, nor is there a specificity of frequency and duration. In those with kidney transplants, given the changing expanded donor policies, higher age at transplantation and reduced fertility in older women, there may be changes in attitudes toward pregnancy in women with less than optimal kidney function.[15] How this will impact short- and long-term outcomes of mothers and their babies is unclear.

Teen pregnancies are very common in some parts of the world and are often associated with low income and education levels. The impact of uneven legal rules for assisted fertilization and the lack of systematic assessment of kidney function require more research.

Despite elegant demonstrations for the role of sex hormones in vascular health and immunoregulation, the striking predominance in females of SLE, RA and SS remains unexplained relative to other systemic diseases such as antineutrophil cytoplasmic antibody vasculitis and hemolytic-uremic syndrome. The incidence of kidney involvement in SLE during pregnancy and similarities/differences in those with PE have not been well studied. The role of different medications and responses to medications for autoimmune diseases relative to sex has also not been well studied.

Attention to similarities between conditions, the importance of sex hormones in inflammation, immune modulation and vascular health may lead to important insights and clinical breakthroughs over time. If women are more likely to be living donors, at differential ages, does this impact both CVD risk and the risk for end-stage kidney disease: have we studied this well enough, in the current era, with modern diagnostic criteria for CKD and sophisticated tools to understand renal reserve? Are the additional exposures that women have after living donation compounded by hormonal changes on vasculature as they age? And are the risks of CKD and PE increased in the younger female living kidney donor?

In the context of specific therapies for the treatment or delay of CKD progression, do we know if there are sex differences in therapeutic responses to angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker? Should we look at dosages and dosage adjustments by sex? If vascular and immune biology is impacted by sex hormones, do we know the impact of various therapies by the level or ratio of sex hormones? In low- and middle-income countries, how do changing economic and social norms impact women's health, and what is the nutritional impact on CKD of the increasing predominance of obesity, diabetes and hypertension?

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