Contraception for All Conceivable Occasions: The CKD Care Gap

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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,¹ although up to 30% of pregnancies in the kidney transplant population are unplanned.² 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.³

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.³ 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 CKD^4,5 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.⁴ 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.^6,7

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.⁸ Considering that many people with CKD, particularly in the advanced stages, view their nephrologist to be their primary care provider,⁹ 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 al¹⁰ 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 al¹⁰ 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.⁶ 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%.⁷ 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.¹¹

Although previous studies have reported infrequent contraceptive counseling by nephrologists or other health care providers,12, 13, 14 the results of the study by Shah et al¹⁰ 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,⁴ 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.¹⁵

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.¹² 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.¹⁴ 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.¹⁶ 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.¹⁷ 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.¹⁸

Participants in the study by Shah et al¹⁰ 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.⁴ 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,¹⁹ 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,^3,20 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 al¹⁰ 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.