Abstract
Introduction
Chronic kidney disease (CKD) affects ≤6% of females of childbearing age, with pregnancy posing considerable health risks. Despite this, contraceptive use among this population remains low, and nephrologists’ perspectives remain underexplored.
Methods
In this cross-sectional study, we used a 52-item electronic survey of US nephrologists to assess their practices and confidence related to reproductive health care for female patients with CKD. Descriptive and bivariate analyses were used to explore associations with provider characteristics.
Results
Among 104 respondents, most practiced in academic settings, and more than half had seen > 15 female patients of childbearing age with CKD in the past year. Reproductive health issues were infrequently addressed, with most “rarely/never” discussing sexual dysfunction (82%), menstrual disorders (59%), or contraception (31%). More than half were “not at all confident” in managing sexual dysfunction (54%), followed by menstrual disorders (42%). Common barriers included lack of standardized guidelines (39%), limited time (38%), and knowledge gaps (33%). More than half reported that the absence of guidelines decreased their likelihood of counseling. A patient receiving a kidney transplant was the factor that most positively influenced the provider’s decision to provide reproductive health counseling. Nephrologists who saw more female patients annually reported significantly higher confidence in managing contraception (30% vs. 11%, P = 0.043), breastfeeding (38% vs. 14%, P = 0.0107), antihypertensives (85% vs. 57%, P = 0.0029), and immunosuppression (63% vs. 36%, P = 0.0117).
Conclusion
US nephrologists reported limited confidence and inconsistent practices in reproductive counseling, underscoring the need for a standardized approach and best practices at a national level to guide care for female patients.
Keywords: chronic kidney disease (CKD), contraception, nephrology, reproductive health
Graphical abstract
CKD affects ≤6% of females of childbearing age, with pregnancy posing a considerable health risk.1 This proportion is expected to increase because of an increasing trend of delayed childbearing,2, 3, 4 as evidenced by a growing number of deliveries among female patients undergoing hemodialysis and kidney transplants.5 Despite this, contraceptive use among female patients with CKD is reported to be as low as 10%6,7 and only 13% of patients discuss reproductive health with their nephrologists, even though half of the patients were sexually active.2 An estimated 37% to 93% of pregnancies in kidney transplant recipients are unplanned8,9 with increased risk of preeclampsia and preterm delivery.10,11
Patients frequently report insufficient counseling and a lack of interdisciplinary coordination regarding contraceptive use.6,12 Only 35% of nephrologists routinely engage in discussions about fertility and contraceptive options, whereas > 65% have reported low confidence in managing female patients’ health issues.3,13,14 Nevertheless, the specific barriers contributing to these gaps in care remain unclear and there is a limited understanding of how frequently specific reproductive topics such as menstrual health, sexual health, and breastfeeding are addressed and what factors drive these conversations. This study addressed this gap by employing a quantitative survey methodology to assess nephrologists’ practices, influential clinical factors, and perceived barriers related to contraception and reproductive health in female patients with CKD; and provided valuable insights for developing targeted interventions to improve the reproductive care of this population.
Methods
This study employed a 52-item electronic cross-sectional survey disseminated to nephrologists across the USA (Supplementary Table S1). The survey included an embedded consent document. Ethics approval was obtained from the University of Cincinnati Office of Human Research Ethics (approval number: 2024-0345) and deemed exempt from requiring participants to sign consent, given the anonymous design of the data collection.
Survey Design and Content
The data were collected and managed using REDCap electronic data capture tools hosted at the University of Cincinnati.15,16 The questions were formulated through a combination of literature review, including previous national and international survey studies,3,13,14,17 and consultation with nephrologists in the field. Before full deployment, the survey underwent pilot testing among a group of 5 nephrologists for assessment of face validity, clarity, and functionality of the survey.
The survey was structured into 6 distinct sections as follows: (i) demographics; (ii) concerns identified by female patients; (iii) reproductive health concerns addressed by physicians, including referral practices; (iv) physician confidence in addressing reproductive health for female patients with kidney disease; (v) influences on physician counseling regarding contraception and reproductive health in female patients with CKD; and (vi) barriers and resources. The full survey instrument is provided in the Supplemental Material.S1
Responses were primarily collected using Likert scales,18 with optional free-form comment sections.
Study Sample and Dissemination
The targeted participants were adult nephrologists in the USA with experience or involvement in the care of female patients with CKD. Recruitment was conducted via email through professional networks and directories of nephrology providers, with survey responses collected between June 2024 and February 2025. Snowball sampling was also employed, with participants encouraged to share the survey link with other colleagues.19 Participants were instructed in the invitation email to complete only 1 survey entry, even if they received multiple invitations, to prevent multiple participation.
Statistical Analysis
Initial data excluded participants who did not fully complete the survey or did not meet the eligibility criteria of being an adult nephrologist. Additional exclusion criteria were applied to remove nephrologists without experience managing female patients of childbearing age, defined as respondents who reported seeing 0 female patients aged 15 to 49 years with CKD, on dialysis, or with kidney transplants in the past 12 months. Given the low rate of missing data (< 5%), no imputation was performed. For survey topics addressing pregnancy-related care (breastfeeding, postpartum care, pregnancy-related immunosuppression, and pregnancy antihypertensive management), nephrologists reporting no encounters with pregnant female patients in the past 12 months were excluded from this subgroup.
Response profiles were visualized using graphical representations. Demographics, clinical practice characteristics, and response frequencies were summarized using descriptive statistics (i.e., percentages or frequencies) in univariate analyses. Bivariate analyses were conducted to compare survey responses across the following demographics subgroups; age (≤ 40 vs. > 40 years), sex (man vs. woman), years in practice (≤ 10 vs. > 10 years), clinical scope (general nephrology vs. transplant nephrology), number of female patients of childbearing age seen in the last year (≤ 15 vs. > 15), and number of pregnant patients seen in the last year (≤ 5 vs. > 5).
Comparisons were performed using Pearson’s chi-square test. Fisher exact test was performed for expected frequencies < 5. Before bivariate analyses, ordinal variables were dichotomized as follows: frequency of topics discussed (never/rarely/sometimes vs. often/always), confidence levels (not at all confident/slightly confident/somewhat confident vs. very confident/quite confident), and barriers (not limiting at all/slightly/moderately vs very/extremely limiting). All statistical analyses were performed using R Statistical Software (version 4.4.1; R Foundation for Statistical Computing, Vienna, Austria).20
Results
A total of 2263 nephrologists were invited, 121 responded (5.3%), with 104 eligible for analysis after exclusions. The response rate was calculated as the number of completed surveys divided by the number of invitations sent. Demographic details of the analyzed sample include 51% females and 49% males, with a median age range of 41 to 50 years and a median range of 6 to 10 years in practice. In terms of clinical scope, 76% identified as general nephrologists and 24% as transplant nephrologists. The majority (58%) saw > 15 female patients of childbearing age in the past year, and 78% practiced solely in an academic setting.
Thirty-three respondents (27.7%) reported seeing 0 pregnant female patients in the past 12 months, leaving a subgroup of 80 for pregnancy-related analyses.
Reproductive Health Concerns Identified by Female Patients
In Figure 1a, we summarize the frequency with which female patients of childbearing age raised specific reproductive health topics during consultations as reported by nephrologists. Sexual dysfunction was the least frequently discussed topic, the majority (90%) of respondents indicating that patients “never/rarely” brought it up. In addition, majority of nephrologists reported that the topics of infertility (70%) and menstrual abnormalities (61%) were “never/rarely” raised by patients.
Figure 1.
(a) Frequency of reproductive health topics reported by nephrologists as being brought up by their female patients of childbearing age with kidney disease (n = 104 respondents, 100% response rate). (b) Frequency of reproductive health topics reported by nephrologists as being brought up by their pregnant patients with kidney disease (n = 80 respondents, 100% response rate).
In contrast, contraception and family planning were more commonly discussed, with only 39% of nephrologists reporting that patients “never/rarely” raised the topic, and 15% indicating it was “often/always” discussed. Pregnancy-related risks were more likely to be patient-initiated, with only 38% reporting it was “never/rarely” brought up, whereas 21% indicated it was “often/always” discussed. A majority reported that breastfeeding concerns (66%) and postpartum care (65%) were “never/rarely” raised by patients (Figure 1b).
Reproductive Health Concerns Addressed by Physicians
In Figure 2, we show the frequency of reproductive health issues addressed by nephrologists during encounters with female patients of childbearing age. Sexual dysfunction was least frequently addressed, with 82% of physicians “never/rarely” bringing it up. Menstrual abnormalities were rarely discussed by physicians, with 59% reporting that they “never/rarely” addressed the topic. Contraception and family planning were the most addressed topics, with only 31% reported “never/rarely” whereas nearly half (47%) of physicians “often/always” discussed them. Among nephrologists with recent experience managing pregnant patients, breastfeeding safety was variably addressed, with 38% reporting they “never/rarely” raised the topic.
Figure 2.
Frequency of reproductive health topics discussed by nephrologists with their female patients of childbearing age with kidney disease (n = 104 respondents, 100% response rate).
In terms of referral practices for reproductive health concerns, 27% of physicians reported “never/rarely” referring patients for reproductive health concerns, 35% indicated they did so “sometimes,” and 38% reported referring patients “often/always.”
Among nephrologists who counseled female patients about contraception, 63% reported recommending intrauterine devices, making intrauterine devices the most frequently endorsed method. Barrier methods were recommended by 46%. Estrogen/progestin combination methods (35%) and progestin-only methods (38%) were recommended similarly. Sterilization was rarely recommended (7%) (Figure 3).
Figure 3.
Frequency of nephrologists’ recommended contraceptive methods for their female patients of childbearing age with kidney disease (n = 104 respondents, 100% response rate).
Physician Confidence in Addressing Reproductive Health for Female Patients With Kidney Disease
In Figure 4a, we present nephrologists’ self-reported confidence in managing reproductive health concerns for female patients with kidney disease. Confidence was particularly low for managing sexual dysfunction (54%) and menstrual abnormalities (42%), indicating “no confidence at all.” Contraception and family planning stood out as areas where nephrologists felt relatively more confident, with only 13% reporting being “not at all confident” and 22% expressing high confidence in managing contraceptive care for female patients with kidney disease.
Figure 4.
(a) Nephrologists’ confidence in managing reproductive health topics in their female patients of childbearing age with kidney disease (n = 104 respondents, 100% response rate). (b) Nephrologists’ confidence in managing pregnancy-related topics in their female patients with kidney disease (n = 80 respondents, 100% response rate).
Meanwhile, confidence in managing antihypertensive medication during pregnancy was highest, with 78% of respondents reporting they felt “quite/very confident.” In managing immunosuppression preconception and during pregnancy, 60% felt “quite/very confident,” whereas self-reported confidence in managing breastfeeding concerns was lower with only 34% feeling “quite/very confident” (Figure 4b).
Influences on Physician Counseling Regarding Contraception and Reproductive Health in Female Patients With CKD
In Figure 5, we show the factors influencing nephrologists’ decisions to provide counseling on contraception and reproductive health for female patients of childbearing age. Nephrologists reported that their decision to provide counseling was strongly or slightly decreased by a paucity of guidelines (56%) and the length of the visit (47%). Similarly, scheduled follow-ups with a primary care physician were reported to decrease counseling likelihood for 41% of respondents. Less than half (38%) reported increased counseling efforts for female patients with nondialysis or nontransplant CKD. Meanwhile, 48% indicated that dialysis or impending dialysis increased their counseling efforts. Kidney transplantation had the most positive impact, with 71% of nephrologists noting an increased likelihood of providing counseling for transplant recipients or candidates.
Figure 5.
Factors influencing nephrologists’ decision to provide reproductive health and contraceptive counseling to their female patients with kidney disease (n = 104 respondents, 100% response rate) CKD, chronic kidney disease; PCP, primary care physician.
Barriers and Resources
In Figure 6, we demonstrate the frequency of barriers reported by nephrologists as limiting contraceptive and reproductive health counseling in female patients with kidney disease. The most limiting barrier was a lack of standardized guidelines, with 39% of respondents rating it as “very/extremely limiting,” followed by limited appointment time (38%) and knowledge gaps regarding reproductive health in CKD (33%). In contrast, the least limiting factors were discomfort in discussing sensitive topics (13%), assumptions about patient interest (13%), and cultural sensitivity (18%).
Figure 6.
Frequency of barriers reported by nephrologists as limiting contraceptive and reproductive health counseling in their female patients with kidney disease (n = 104 respondents, 100% response rate).
Qualitative Responses
The end of the survey included a free-response item asking participants to identify resources that would enhance reproductive and contraceptive counseling among nephrologists. A total of 24 responses were received. The most frequently cited theme was the need for clinical guidelines (n = 17), followed by educational materials (n = 4), professional development opportunities (n = 3), and increased interdisciplinary collaboration (n = 3).
Associations Between Provider Traits and Counseling
In Table 1, we provide the demographic characteristics of the nephrologists who reported that female patients frequently brought up reproductive health topics to them. Patients were reported to have significantly more discussion about the topic of pregnancy risk complications with a general nephrologist than the topic of transplant (26.6% vs. 4%, P = 0.033). Infertility was discussed more with nephrologists who had seen > 15 female patients with CKD in the past year as compared to < 15 with CKD (10% vs. 0%, P = 0.038). Contraception (31.8% vs. 11.0%, P = 0.040) and risk of pregnancy complications (40.9% vs. 15.9%, P = 0.018) were discussed more by patients with providers who had seen > 5 pregnant patients in the past year as compared to < 5 pregnant patients.
Table 1.
Demographic characteristics of nephrologists who reported that their female patients “often/always” brought up the reproductive health topics of sexual dysfunction, menstrual abnormalities, contraception/family planning, risk of pregnancy complications, and infertility
| Demographics | Reproductive health topics |
||||
|---|---|---|---|---|---|
| Sexual dysfunction | Menstrual abnormalities | Contraception/family planning | Risk of pregnancy complications | Infertility | |
| Age | |||||
| ≤ 40 yrs | 4.3% | 13.0% | 21.7% | 17.4% | 8.7% |
| > 40 yrs | 0.0% | 8.6% | 10.3% | 24.1% | 3.4% |
| Sex | |||||
| Male | 2.0% | 5.9% | 13.7% | 27.5% | 3.9% |
| Female | 1.9% | 15.1% | 17.0% | 15.1% | 7.5% |
| Years of practice | |||||
| ≤ 10 yrs | 3.0% | 13.4% | 19.4% | 20.9% | 9.0% |
| > 10 yrs | 0.0% | 5.4% | 8.1% | 21.6% | 0.0% |
| Clinical scope | |||||
| Transplant | 4.0% | 12.0% | 12.0% | 4.0%a | 0.0% |
| General | 1.3% | 10.1% | 16.5% | 26.6%a | 7.6% |
| Female patients of child bearing age with CKD seen yearly | |||||
| ≤ 15 patients | 2.3% | 9.1% | 9.1% | 13.6% | 0.0%a |
| > 15 patients | 1.7% | 11.7% | 20.0% | 26.7% | 10.0%a |
| Pregnant patients with CKD, dialysis or transplant seen in last 12 mos | |||||
| ≤ 5 pregnant patients | 2.4% | 11.0% | 11.0%a | 15.9%a | 3.7% |
| > 5 pregnant patients | 0.0% | 9.1% | 31.8%a | 40.9%a | 13.6% |
CKD, chronic kidney disease.
P-value < 0.05.
In Table 2, we provide the frequency of how often nephrologists themselves brought up certain reproductive topics, by demographic characteristics. Nephrologists who had cared for > 5 pregnant patients in the previous year showed a significantly higher likelihood of talking about the safety of breastfeeding (55% vs. 21%, P = 0.004). In addition, this provider group showed a significant likelihood to refer female patients to another physician to address concerns associated with reproductive health (59% vs. 33%, P = 0.046).
Table 2.
Demographic characteristics of nephrologists who reported “often/always” bringing reproductive health topics of menstrual abnormalities, sexual dysfunction, contraception/family planning, safety of breastfeeding, and referral to another physician for reproductive health
| Demographics | Reproductive health topics |
||||
|---|---|---|---|---|---|
| Menstrual abnormalities | Sexual dysfunction | Contraception/family planning | Safety of breastfeeding | Referral for reproductive health | |
| Age | |||||
| ≤ 40 yrs | 4% | 2% | 50% | 28% | 43% |
| > 40 yrs | 10% | 2% | 45% | 28% | 34% |
| Sex | |||||
| Male | 6% | 2% | 45% | 27% | 35% |
| Female | 9% | 2% | 49% | 28% | 42% |
| Years of practice | |||||
| ≤ 10 yrs | 5% | 2% | 51% | 25% | 39% |
| > 10 yrs | 11% | 2% | 43% | 32% | 38% |
| Clinical scope | |||||
| Transplant | 12% | 4% | 64% | 20% | 44% |
| General | 6% | 1% | 42% | 30% | 37% |
| Female patients of childbearing age with CKD, dialysis or transplant seen in last 12 mos | |||||
| ≤ 15 patients | 9% | 2% | 41% | 18% | 27% |
| > 15 patients | 7% | 2% | 52% | 35% | 47% |
| Pregnant patients with CKD, dialysis or transplant seen in last 12 mos | |||||
| ≤ 5 pregnant patients | 7% | 1% | 43% | 21%a | 33%a |
| > 5 pregnant patients | 9% | 5% | 64% | 55%a | 59%a |
CKD, chronic kidney disease.
P-value < 0.05.
In Table 3, we provide the confidence of nephrologists by demographic characteristics. Nephrologists who reported managing > 15 female patients of childbearing age within the past year demonstrated significantly higher confidence in addressing topics such as contraception (30% vs. 11%, P = 0.043), immunosuppression (63% vs. 36%, P = 0.012), breastfeeding (38% vs. 14%, P = 0.011), and antihypertensive management during pregnancy (85% vs. 57%, P = 0.003), than those who had seen < 15 patients. Similarly, providers with > 5 yearly pregnant patients reported having significantly higher confidence in contraception (41% vs. 17%, P = 0.023) and immunosuppression (77% vs. 45%, P = 0.015). Female nephrologists reported significantly higher confidence in managing contraception than their male counterparts (32% vs. 12%, P = 0.024). Transplant nephrologists reported greater confidence in managing immunosuppression during the peripartum period than general nephrologists (80% vs. 43%, P = 0.003).
Table 3.
Demographic characteristics of nephrologists who reported “quite confident/very confident” in counseling or managing health topics of menstrual abnormalities, sexual dysfunction, contraception/family planning, immunosuppression preconception and during pregnancy, breastfeeding, and antihypertensive medication during pregnancy
| Demographics | Reproductive health topics |
|||||
|---|---|---|---|---|---|---|
| Menstrual disorders | Sexual dysfunction | Contraception/family planning | Immunosuppression preconception and during pregnancy | Breastfeeding | Antihypertensive medication during pregnancy | |
| Age | ||||||
| ≤ 40 yrs | 0% | 0% | 22% | 59% | 28% | 74% |
| > 40 yrs | 5% | 2% | 22% | 47% | 28% | 72% |
| Sex | ||||||
| Male | 2% | 0% | 12%∗ | 55% | 20% | 76% |
| Female | 4% | 2% | 32%∗ | 49% | 36% | 70% |
| Years of practice | ||||||
| ≤ 10 yrs | 2% | 0% | 25% | 58% | 26% | 72% |
| > 10 yrs | 4% | 2% | 19% | 45% | 30% | 74% |
| Clinical scope | ||||||
| Transplant | 8% | 4% | 36% | 80%a | 40% | 76% |
| General | 1% | 0% | 18% | 43%a | 24% | 72% |
| Female patients of child bearing age with CKD, dialysis or transplant seen in last 12 mos | ||||||
| ≤ 15 patients | 2% | 0% | 11%a | 36%a | 14%a | 57%a |
| > 15 patients | 3% | 2% | 30%a | 63%a | 38%a | 85%a |
| Pregnant patients with CKD, dialysis or transplant seen in last 12 mos | ||||||
| ≤ 5 pregnant patients | 2% | 0% | 17%a | 45%a | 24% | 68% |
| > 5 pregnant patients | 5% | 5% | 41%a | 77%a | 41% | 91% |
CKD, chronic kidney disease.
P-value < 0.05.
In Table 4, we provide how limiting specific barriers were to nephrologists by demographic characteristics. Nephrologists who had seen < 15 female patients of childbearing age were significantly more likely to cite knowledge gaps as a major barrier to counseling (45% vs. 23%, P = 0.030). Notably, no significant differences were found in the perceived impact of barriers based on the nephrologist’s age, sex, or years in practice.
Table 4.
Demographic characteristics of nephrologists who indicated that the following barriers “very/extremely limit” their ability to provide reproductive health counselling to their female patients with CKD
| Demographics | Perceived barriers |
||||||
|---|---|---|---|---|---|---|---|
| Knowledge gap | Assumption about patient being uninterested of such counseling | Lack of standardized guidelines | Cultural sensitivity | Discomfort discussing such sensitive topics | Limited appointment time | Lack of interdisciplinary coordination | |
| Age | |||||||
| ≤ 40 yrs | 33% | 9% | 41% | 13% | 9% | 41% | 28% |
| > 40 yrs | 33% | 16% | 38% | 22% | 16% | 36% | 34% |
| Sex | |||||||
| Male | 25% | 16% | 35% | 22% | 14% | 37% | 29% |
| Female | 40% | 9% | 43% | 15% | 11% | 40% | 34% |
| Yrs of practice | |||||||
| ≤ 10 yrs | 30% | 9% | 40% | 14% | 9% | 42% | 30% |
| > 10 yrs | 36% | 17% | 38% | 23% | 17% | 34% | 34% |
| Clinical scope | |||||||
| Transplant | 20% | 8% | 28% | 20% | 12% | 24% | 32% |
| General | 37% | 14% | 43% | 18% | 13% | 43% | 32% |
| Female patients of child bearing age with CKD, dialysis or transplant seen in last 12 mos | |||||||
| ≤ 15 patients | 45%a | 20% | 50% | 27% | 11% | 45% | 39% |
| > 15 patients | 23%a | 7% | 32% | 12% | 13% | 33% | 27% |
| Pregnant patients with CKD, dialysis or transplant seen in last 12 mos | |||||||
| ≤ 5 pregnant patients | 34% | 15% | 43% | 21% | 12% | 39% | 35% |
| > 5 pregnant patients | 27% | 5% | 27% | 9% | 14% | 36% | 18% |
CKD, chronic kidney disease.
P-value < 0.05.
Discussion
Our study examined at provider practices surrounding sexual dysfunction, menstrual irregularities, contraception, and breastfeeding, and found low rates of discussion and inconsistent practices. In addition, our findings suggest that nephrologists are more likely to engage in counseling during later stages of kidney disease. Key barriers included a lack of guidelines and limited time.
Our study highlights the low engagement around the topic of sexual dysfunction in clinical discussions from both the nephrologist and patients. Female-specific meta-analyses show a substantial burden, with ≤ 80% of patients with CKD reporting sexual health issues,21, 22, 23, 24 often linked to depression and hormonal disruption.25, 26, 27, 28
Despite this burden, health care engagement remains poor. Our findings showed that the majority of nephrologists rarely initiate or feel confident discussing sexual health. These survey results further support the idea that gynecological problems are often unrecognized and unaddressed by nephrologists in this female patient population.17,29
Even though female patients with CKD who experience sexual difficulties have reported interest in learning about possible treatment options,30 our study found that a majority (90%) of nephrologists indicated that female patients did not bring up this topic. Patients not expressing their sexual health concerns have been reported as the most important barrier to initiating these conversations in a study among Dutch nephrologists.17 This communication gap may stem from a feedback cycle of patients reluctant to raise sexual concerns, compounded by provider discomfort, resulting in low consultation rates. Recognizing patient interest in treatment underscores the critical need for proactive provider inquiry. Given the room for expansion in the female sexual dysfunction guideline,31,32 this remains an important point of improvement. Embedding brief sexual health screening tools or promoting quick access resources (such as the “Kidney Commute CE Study Guide: Sexuality and Kidney Disease”) could normalize these discussions and improve referrals and outcomes.33
Menstrual irregularities are another prevalent aspect of patients’ health among the CKD and dialysis population, with prevalence estimates ranging up to 75% on peritoneal dialysis.34 Irregular bleeding caused by impaired pulsatile gonadotropin-releasing hormone secretion exacerbates anemia and may necessitate transfusions, further complicating CKD management.13,29,35, 36, 37 These disruptions are further stressed because irregular and long menstrual cycles in adulthood are associated with a greater risk of premature mortality.38
Despite this prevalence and potential complications, menstrual issues are infrequently addressed in the nephrology setting. Our results showed that 61% of nephrologists reported that patients “rarely” bring up these concerns, and 59% did not initiate such discussions themselves. Furthermore, almost half (42%) lacked confidence in managing menstrual disorders, following the trend of previously reported low confidence in both adult and pediatric nephrologists.3,39 Although nephrologists recognize CKD’s hormonal effects,13 few discuss menstrual concerns, underscoring the need for structured interventions
Contraceptive counseling emerged as the most actively addressed health topic, although 31% still “never/rarely” do so, signaling a range of practices and a provider hesitation that has previously been reported among nephrologists.3,14 Nephrologists reported that patients were more likely to initiate discussions about contraception than sexual dysfunction or menstrual abnormalities. Contraception management emerged as an area where nephrologists reported relatively higher confidence. Intrauterine devices were most often recommended, endorsed by 63% of nephrologists, followed by barrier methods. The typical-use failure rates of barrier methods40,41 are particularly concerning in the CKD population, where unplanned pregnancy poses significant health risks.
Our bivariate analysis showed that nephrologists managing a higher patient load of reproductive-age or pregnant patients reported greater confidence managing contraception, alongside immunosuppression, breastfeeding, and the use of antihypertensives during pregnancy. Notably, whereas previous studies have shown greater provider confidence with increased years of clinical experience,3 our findings did not show a significant association between years in practice and confidence, counseling frequency, or the impact of perceived barriers.
Furthermore, these data support the value of case-based experience with appropriate patient populations as a potentially effective approach to enhancing clinician competence rather than time in practice alone without relevant patient encounters.
Breastfeeding offers well-established benefits for mothers and infants,42, 43, 44 and is supported for female patients with CKD, including transplant recipients.45, 46, 47 In our study, breastfeeding was inconsistently addressed, with one-third of nephrologists rarely discussing it. Providers with more pregnant patients were more likely to initiate these conversations (P = 0.004). This may reflect the development of a routine or an increased level of comfort and experience with managing these discussions.
In terms of confidence, only 34% of nephrologists reported being confident discussing breastfeeding. A higher confidence was positively associated with the number of reproductive-age female patients they had managed (P = 0.011). The observed variation in discussion frequency and provider confidence may help explain the previous literature that cites patients’ frustration with inconsistent breastfeeding guidance and the lack of a single physician specialty leading management.48 Ensuring a more unified messaging could help reduce delay in breastfeeding initiation and reduce the risk of CKD-related conditions such as hypertension and diabetes.49
Although previous research has documented the general underutilization of reproductive and contraceptive counseling, the extent to which patient disease status influences provider behavior has been less well-characterized. Our study identified a staged increase in counseling from nondialysis CKD (38%) to dialysis (48%) and transplant (71%). The higher rates of consultation for transplant patients likely reflect providers’ awareness of the restoration of fertility posttransplant.50,51 Consequently, counseling efforts may become more focused on the peritransplant period, aiming to prevent high-risk pregnancies during this vulnerable window.
Interestingly, a notable increase in counseling was observed at the dialysis initiation stage, despite dialysis being associated with significantly reduced fertility rates.52, 53, 54 One potential explanation is that nephrologists may interpret dialysis initiation as a clinical inflection point warranting broader discussions of reproductive health. Alternatively, providers may feel more comfortable initiating these discussions because of increased contact time and a stronger rapport with patients during dialysis care.
Nevetheless, unplanned pregnancy risk persists across CKD stages.55 Thus, reproductive discussions should ideally begin at the earliest adult CKD encounters. In addition, qualitative research suggests that many female patients with CKD value proactive counseling on fertility and contraception, even in early stages of disease progression.56 The use of structured reproductive assessments in routine CKD care, including initial CKD staging visits, may help close this gap.
Lack of standardized guidelines and best practices emerged as the primary barrier, negatively affecting 56% of nephrologists’ decision to counsel, and was deemed “very/extremely limiting” by 39%. This concern was reinforced in the qualitative responses, where 17 out of 24 participants cited the need for guidelines when asked about resources that would enhance counseling. This builds on previous work showing that 83% of nephrologists stated that interdisciplinary guidelines from obstetrics and nephrology would improve counseling and management of female patients with CKD.3
Although clinical practice statements and society guidelines have been developed,57, 58, 59 their integration into routine nephrology practice seems to be uncertain. This raises important questions about the awareness, accessibility, and usability of these resources among nephrologists. Evaluation of nephrologists’ perception and use of the current guidelines could provide further insight into the gap between the providers’ practice and established guidelines. It is possible that existing guidelines and best practices lack clinical visibility, are perceived as too general, or are not aligned with the workflow of nephrology visits. In addition, if nephrologists have not received formal training in reproductive health, even well-developed resources may feel inaccessible or insufficient to build confidence. Understanding this issue could inform strategies to improve the presentation and dissemination of current guidelines, as well as guide the development of future resources.
There are several limitations of this study. The sample was predominantly composed of respondents affiliated with academic practice settings, which along with the low response rate, may limit the generalizability of the findings. Snowball sampling and self-selection may have introduced additional selection bias, because respondents who completed the survey might have greater knowledge or interest in the topic. Social desirability bias may have influenced nephrologists to provide responses they believed would be viewed more favorably. Finally, given the cross-sectional survey and reliance on self-reported data, the findings may be subject to recall bias.
Survey results indicate that US nephrologists report low confidence and inconsistent practices in managing sexual dysfunction, menstrual abnormalities, breastfeeding, and contraception among female patients. The absence of standardized clinical guidelines emerged as a major barrier to counseling. Greater exposure to reproductive-age female patients with CKD was associated with increased provider confidence in addressing these topics. These findings emphasize the need for guideline implementation in clinical practice to improve reproductive counseling and outcomes for female patients with kidney disease.
Disclosure
All the authors declared no competing interests.
Author Contributions
NS initiated the study, designed, and conducted the study. NS and DL analyzed and interpreted the data. RN contributed to the study design and data interpretation. SS assisted NS with study design and implementation. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual’s own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, are appropriately investigated and resolved, including with documentation in the literature, if appropriate.
Acknowledgments
This research was supported by the University of Cincinnati Department of Internal Medicine’s IMSTAR Student Research Experience.
Funding
Silvi Shah was supported by the K23 career development award, under award number 1K23HL151816-01A1, National Heart, Lung, and Blood Institutes (NHLBI), National Institute of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funders of the study had no role in study design; collection, analysis, and interpretation of data; writing the report; and the decision to submit the report for publication.
Footnotes
Supplementary Methods.
Table S1. Full survey instrument used in the study.
CROSS Checklist.
Supplementary Material
Supplementary Methods. Table S1. Full survey instrument used in the study. CROSS Checklist.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Methods. Table S1. Full survey instrument used in the study. CROSS Checklist.