Reproductive Health Care Is a Key Component of Comprehensive Care for Adolescents with CKD

Navigating adolescence can be an intricate and difficult dance in the best of circumstances. It is a common time of sexual debut and a time of establishing gender identity, sexual orientation, and sexual behaviors. The addition of kidney disease, up to and including kidney failure, can increase the likelihood and consequences of missteps. As nephrologists, we stress the need for our patients to have a primary care provider, yet the reality is that as kidney function deteriorates, the pediatric nephrologist often becomes the de facto primary care provider. However, pediatric nephrologists have expressed a lack of confidence in counseling on sexual health and reported an overall lack of formal training in this topic,¹ ultimately leading to a gap in reproductive health care for adolescents with CKD.

Following the recent Supreme Court decision which held that there is no constitutional right to abortion, we have already begun to witness the reverberations on both access and choice for adolescent patients. A mistimed or unwanted pregnancy can be stressful at any age, but this stress is likely exponentially amplified for an adolescent with CKD. Indeed, given the known risks of pregnancy with underlying CKD and the medications we prescribe with potential fetotoxicity, an unplanned pregnancy coupled with lack of access to abortion care may have lifelong consequences to our patients' health.

It is our job as physicians to provide care that aligns with our patients' goals. When missteps occur, we should do our best to help them get back on track. With dedicated efforts from the entire nephrology community, including an increased focus on reproductive health education in training and multidisciplinary partnerships, we can improve the delivery of true comprehensive care to our adolescent patients.

Adolescent Sexual Health in the United States

The 1980s brought about an increase in adolescent birth rates that led to a broader public health focus on sexual education and contraception use. While rates began to decline in the 1990s, the United States continues to have a significantly higher incidence of adolescent pregnancy compared with other developed nations. This may be in part due to the numerous restrictions of abortion services, transpiring even in the years leading up to the Dobbs v. Jackson Women's Health Organization decision. Adolescents in the United States also remain less likely to receive comprehensive sexual education and are less likely to use the most effective contraceptive methods than their peers in developed nations.²

Compounded by the complexities of confidentiality and the pervasive social stigma and discrimination, adolescents in the United States experience unique obstacles in receiving reproductive health care. These obstacles may arise from overlapping societal (public policies, laws), community (cultural, religious, educational), interpersonal (parents, partners, peers), and individual (knowledge, attitude, behavior) factors. Not surprisingly, high-risk adolescents seen in pediatric subspecialties may be among the most vulnerable to these disparities: An analysis of pediatric clinic visits where teratogens were prescribed found that less than one-third of visits documented counseling, prescriptions, or referrals for contraception.³ Notably, Black adolescents prescribed teratogens had lower odds of receiving these contraception services than White adolescents.³

Adolescent Pregnancy in the General Population

Pregnancy in adolescence is high risk to both the patient and the offspring. Maternal outcomes for adolescent pregnancy include higher rates of hypertensive disorders of pregnancy, including preeclampsia and eclampsia, as well as sexually transmitted infections (STIs), such as gonorrhea and chlamydia.⁴ Adverse perinatal outcomes including infant and neonatal death, prematurity, and congenital birth defects are more common in adolescents.⁴

Pregnancy in the adolescent years is not only physically demanding, but it also leads to increased mental health crises, high school dropout rates, and poverty. In the United States, the racial and ethnic disparities affecting adolescent pregnancy rates and outcomes are disquieting. In 2020, the birth rates for Hispanic adolescents and non-Hispanic Black adolescents were more than two times higher than the rate for non-Hispanic White adolescents.⁵ These disparities are exacerbated by other social determinants of health that diminish access to prenatal care or abortion services. Adolescents in rural areas with unintended pregnancies are less likely to receive an abortion than their urban peers, and this rural-urban gap is particularly wide for Black adolescents.⁶ Following Dobbs, state-specific abortion restrictions will further disproportionately affect young people, as well as people of color, LGBTQ+ people, and people with lower income or living in rural areas—groups that notably also face disparities in diagnosing and treating CKD.

Pregnancy in Adolescents with CKD

Although research specific to adolescent pregnancy in CKD is lacking, pregnancy among adolescents with other underlying chronic medical conditions is known to be high risk. Obese adolescents have more than four times higher risk for cesarean delivery and gestational diabetes than normal-weight adolescents.⁷ Among adolescents with SLE, the adjusted odds of preeclampsia/eclampsia and preterm birth were nearly three times higher compared with peers without SLE.⁸ In nonadolescent women with CKD pre-pregnancy, hypertension and proteinuria serve as important predictors of adverse obstetric outcomes including preterm birth and low birthweight infants. In a heterogeneous group of women with eGFR<60 ml/min per 1.73 m², including those with glomerulonephritis and those with kidney transplant, pregnancy-associated disease progression advanced kidney failure by an average of 2.5 years.⁹ Adolescents with CKD experiencing pregnancy are likely to experience similar, if not worse, outcomes.

Addressing Reproductive Health in Adolescents with CKD

Now more than ever, the care of our adolescent patients must include addressing barriers to sexual and reproductive health (Figure 1). We should not assume that this is being done with other health care providers or in school. In addition, we must strive to provide confidential care. Communication between adolescents and their parents can be encouraged but is not always required; an understanding of state-specific laws regarding parental consent for contraception or abortion is important for all who care for adolescents (https://www.guttmacher.org/state-policy). Candid conversations that occur early and often will allow for ongoing discussions that can evolve over multiple clinic visits and normalizes reproductive health care as an aspect of comprehensive kidney, and adolescent, care. Discussions should encompass sexual orientation, sexual activity, STI, contraception, and pregnancy. Contraception discussions should be structured as a shared decision but should generally begin with information on the most effective methods first, including the intrauterine device (IUD) and the subcutaneous implant, which are compatible with CKD and are not associated with increased infection risk or reduced efficacy among immunosuppressed patients. These have higher efficacy, continuation, and satisfaction rates compared with short-acting contraceptives; this does not differ by age or parity.¹⁰ Unfortunately, in the United States, <5% of current contraception users aged 15–19 years are using these methods.¹¹ Emergency contraception (oral pills or copper-bearing IUD placement) is safe for those with CKD and can prevent pregnancy up to 5 days after intercourse. Advising patients how they can access emergency contraception should be routinely included in discussions about contraception.

Figure 1.

Ways nephrologists can address barriers to adolescent reproductive health care.

Pediatric nephrologists need reproductive health training to address the current discomfort, lack of confidence, and gaps in reproductive health care of our adolescent patients. Promoting preventive reproductive health maintenance and establishing a local pipeline with colleagues who can provide family planning, STI, and obstetric services is essential. Compiling national pregnancy outcome data on this high-risk group is now more pressing to support and inform patients considering abortion and their providers who may have to validate provision of this care. In this post-Roe era, let this be a call to action that together we can take an active seat at the table to advocate for reproductive autonomy among those with CKD. Adolescent patients are relying on us to help them navigate the evolving state-by-state laws and regulations. We must equip ourselves with the knowledge and resources to ensure comprehensive reproductive health care is achieved for each of our patients.

Disclosures

A.L. Oliverio reports Other Interests or Relationships: Research funded by NephCure Kidney International, and Research funded by NIDDK. M. Moxey-Mims reports Consultancy: Reata Pharmaceuticals, Inc; Research Funding: Rockwell Medical and Travere Therapeutics; and Advisory or Leadership Role: JASN Associate Editor, Pediatric Nephrology Editorial Board, NephCure International Scientific Advisory Board, and National Kidney Foundation Scientific Advisory Board. All remaining authors have nothing to disclose.

Funding

None.

Author Contributions

C. Brunson, M. Moxey-Mims, A.L. Oliverio, and M.L. Reynolds conceptualized the study, wrote the original draft, and reviewed and edited the manuscript.