Planning for Family

By Erika Muscat

Pregnancy and Chronic Kidney Disease

The Kidney Foundation held a Virtual Forum in March 2023, with a session dedicated to the theme of families and the journey of living with chronic kidney disease. One of the breakout sessions covered the topic of Family Planning while living with chronic kidney disease featuring the stories of women and their personal reflections and the lessons they’ve learned. We asked nephrologists Dr. Veronica Silva and Dr. Marie-Josée Clermont to answer a few questions to share their insights on some of the most frequently asked questions and why it’s so important to have an open dialogue with your renal team when family planning.

Questions answered by Dr. Veronica Silva

What are the potential fertility and contraception concerns for both men and women with chronic kidney disease?

For women who have reached the later stages of kidney disease, stages 4 & 5 and/or dialysis, ovulation stops unfortunately. This is where fertility becomes difficult and a concern for those wanting to conceive. Your body is already slowing down due to your own kidneys and their functions decreasing, your ovulation will automatically decrease as well.

However, studies have shown that women who are on nocturnal dialysis or home hemodialysis tend to have a better chance at ovulating because dialysis is incorporated on a regular basis. Obviously, there are still risks, such as high blood pressure that would need to be monitored by your nephrologist and high-risk team.

For women who are transplanted, your body and kidney function are considered to have returned to normal. Ovulation should be back on track for most women. Also depending on the age of the person, an option might be to investigate fertility clinics and information regarding freezing their eggs for future planning.

Having the conversation about pregnancy at a younger age will help guide one into making the right informed decision for their future. For men, it’s not so much of a concern. Their bodies can still produce sperm and they have better chances of having children, regardless of them being on dialysis and or diagnosed at a later stage of CKD. On the other hand, erectile dysfunction can be a concern for them throughout CKD, regardless of their stage of kidney disease.

Are there risks associated with being pregnant with chronic kidney disease and what can be done to mitigate these risks?

There are lots of implications and ramifications with being diagnosed with CKD and other related health conditions such as lupus or diabetes, for example, and how well it is controlled and monitored throughout the pregnancy journey. Each person’s body is affected very differently.

Before considering pregnancy, please speak with your doctor. Your physician is aware of the best ways to support your medical condition(s) and when to refer you to a high-risk pregnancy clinic to optimize the best possible outcomes for you and baby.

Questions answered by Dr. Marie-Josée Clermont

In your medical opinion, why is pre-pregnancy counselling essential? What are some other resources that people can use?

Pre-pregnancy counselling is essential for many reasons. First, genetic counselling is recommended for families with a history of known or suspected inheritable renal disease to assist in decision-making regarding pursuing a pregnancy. Referral for specialist counselling with clinical genetics teams may be recommended to facilitate genetic diagnoses, the testing of family members or for discussions regarding the possibility of a pre-implantation - a procedure that is used to reduce the risk of passing inherited conditions.

A person with CKD contemplating pregnancy also needs to be in the best shape they can be such as an optimal weight, well controlled blood pressure and glycemic levels, iron and thyroid levels, no urine infection, etc. If your renal disease is active, you may have to wait a few months after remission before a pregnancy. If you had surgery to your bladder and urinary tract in the past, this may need to be reviewed by a urologist. Your renal team can assist you with all of that. They know you and your level of CKD, and they can help you make a decision that is based on your own personal health. There are many things to consider apart from your kidney disease like diabetes for example or any other conditions you may have. You and your doctor should discuss them all very thoroughly.

Your renal team also needs to be prepared, and they will direct you to the best obstetrical care you can get in your area. You may also have to change your current medication because some classes of medicines are toxic for the unborn baby, and a few weeks may be needed to make sure the new medication is effective and well tolerated.

Clinical practice guidelines include a recommendation for a pre-pregnancy consultation with a high-risk pregnancy team. If you get pregnant, they will take care of you and your pregnancy, in collaboration with the nephrology team. Your first visit must be early because some medicine may be given to lower the risk of complication, such as preeclampsia.

Pregnancy in a woman with more advanced CKD can be more complicated with risks such as, urinary tract infections, hypertension, pre-eclampsia, premature labor, restricted growth of the baby, and decrease in the mother’s own renal function. The possibility of having a caesarean section is also higher. The mother may have to take time off and/or be hospitalised for periods of time to ensure that she stays healthy and that the baby develops as expected.

The woman and her partner must be prepared for all these potential complications and for the risk of having a premature baby. It is also recommended if the CKD is advanced, that you receive pre-dialysis education.

Why is having an open and honest communication with your renal team about your expectations important?

You need an honest conversation with your doctor and with the renal team beforehand to prepare yourself and your partner to all eventualities and realign your expectations with the facts.