For Kidneys Sake
For Kidneys' Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS)
This podcast series aims to provide healthcare professionals, particularly primary care professionals, with accessible insights into kidney health.
Each episode offers bite-sized discussions on key topics such as chronic kidney disease management and heart failure and practical updates for improving patient care. With episodes just 15 minutes long, you can listen on your commute, during a break, or while out for a walk. Join us as we explore the latest advancements and strategies in integrated kidney care to empower clinicians and patients alike.
For Kidneys Sake
You want a baby? CKD, fertility and pregnancy: don't fail to plan
The For Kidneys Sake podcast series is brought to you by Imperial College Healthcare NHS Trust and North West London Integrated Care Board (NWL NHS).
In this discussion, consultant nephrologists Prof Jeremy Levy and Dr Andrew Frankel are joined by Dr Phil Webster to examine fertility and pregnancy in the context of chronic kidney disease (CKD). They highlight that while many CKD patients are older, a significant number of younger individuals, especially those with inherited or congenital kidney conditions, will face issues related to fertility and pregnancy. CKD affects approximately 3% of pregnancies, and the severity of kidney disease directly influences fertility and pregnancy outcomes.
The conversation is structured into three key areas: fertility in men and women with CKD, pre-pregnancy counselling for women with CKD, and management during pregnancy. They emphasise that fertility is usually preserved in mild CKD but may decline with worsening kidney function. All women with CKD considering pregnancy should receive pre-pregnancy counselling to review medications, optimise blood pressure, and understand potential risks such as pre-eclampsia and accelerated kidney function decline. During pregnancy, specialist monitoring is essential. Women with CKD should ideally be managed through multidisciplinary maternal medicine networks, and contraceptive advice should be part of routine nephrology care.
Key Takeaways:
- Fertility is generally unaffected in early CKD but declines as kidney function worsens; both men and women with advanced CKD may require specialist input.
- Women with CKD should receive pre-pregnancy counselling to adjust medications, optimise kidney and blood pressure control, and assess risks, particularly of pre-eclampsia and kidney function loss.
- Pregnancy in CKD requires enhanced monitoring through specialist clinics, with coordinated care across nephrology and obstetrics to ensure maternal and fetal health.
Resource Links:
NICE GUIDELINES [NG203] chronic kidney disease: assessment and management Overview | Chronic kidney disease: assessment and management | Guidance | NICE
Northwest London CKD guidelines for primary care Chronic kidney disease (nwlondonicb.nhs.uk)
The purpose of this podcast is to inform and educate health care professionals working in the primary care and community setting. The content is evidence based and consistent with NICE guidelines and North West Guidelines available at the time of publication.
The content of this podcast does not constitute medical advice and it is not intended to function as a substitute for a healthcare practitioner’s judgement.
Produced by award-winning media and marketing specialist Heather Pownall of Heather's Media Hub
Jeremy Levy
So, hello, I'm Jeremy Levy. I'm a consultant nephrologist at Imperial College Healthcare NHS Trust.
Andrew Frankel
And I'm Andrew Frankel, a colleague of Jeremy's also at Imperial College Healthcare NHS Trust. And it is a real pleasure today to have Dr. Phil Webster join us since he is a major expert in the area that we are going to discuss. And he runs our local pre-pregnancy clinic and helps us manage the many women who have pregnancy and kidney disease.
Phil Webster
Thank you both. I'm Phil Webster. I'm also a consultant nephrologist at Imperial College Healthcare NHS Trust and it's great to be here to discuss this really important topic which we do need to talk about.
Andrew Frankel
So Phil, we want to talk about pregnancy and fertility in the context of chronic kidney disease or CKD. Now most of our patients with CKD are older and many are substantially older and therefore these issues are often of less importance but there are still, and I'm sure you're going to highlight this, a significant number of younger women and then with CKD in whom these issues are relevant and important.
And I didn't realise, but you told me before this podcast, that CKD affects around 3 % of pregnancies. That's not a small number. And so GPs will need to know about this, even if only an outline.
Jeremy Levy
And I was staggered by that number as well, Andrew. I 3 % much higher number than I would have guessed. But of course, we've also got a big cohort of relatively younger patients. And there's a huge amount of misinformation out there about pregnancy and chronic kidney disease. And if people Google it, they'll always think about patients on dialysis and with transplants. And we remember, don't we, that up to 20 % of people with CKD, chronic kidney disease, have got as the cause of their CKD polycystic kidney disease or congenital abnormalities and these people are going to be on average younger in their 20s with CKD and therefore pregnancy and fertility will be an issue. as we were chatting about this before we think there are going to be three areas that we're going to focus on in this chat today. The one is going to be about fertility and advice for men and women regarding fertility when they have CKD. There'll be advice for women with CKD who are planning a possible pregnancy. And then once they get pregnant, advice for pregnant women with CKD and what they should know and to do about it. And those are the three sort of big areas. And we're to briefly touch on some inherited kidney disease issues a bit later. So Phil, should we start with that first topic, which is about fertility? I'm going to ask you direct question. Are women with known CKD less able to get pregnant?
Phil Webster
Well look, fertility problems aren't uncommon in the general population and we do know that having kidney disease can affect fertility and this completely relates to your stage of kidney disease, your GFR and the worse your kidney disease, the higher the stage and the lower your GFR, the more likely you are to have fertility problems and sub-fertility and to potentially require assisted fertility. So I think it's worth starting with for the majority of patients who have mild or early kidney disease, fertility will not be affected. And so there's a huge difference between a woman who has early or mild kidney disease, maybe reflux nephropathy with CKD stage G2 and EGFR of 65 mls per minute, minimal proteinuria.
Comparing that with a woman who may have advanced CKD stage four or five in whom fertility, there's a much higher chance that that will be affected.
Phil Webster
And the main issue is actually the GFR itself and that might be related to toxin levels, so microscopic haematuria, even conditions like lupus is a cause of kidney disease. If you have normal kidney function, then your fertility should not be affected. So the worse your GFR, the more likely you are to have sub-fertility. Despite all of this, many or most women will be able to get pregnant.
What we do advocate in our population of patients is early referral to fertility services for women. We mustn't forget that men can also be affected and again the more advanced your kidney disease, the lower your EGFR, the more likely men can be affected. They may have hypogonadism, hormone dysregulation, reduced sperm quality and effects on libido. But in the end, again, men with kidney disease usually can go on to father children.
Andrew Frankel
So Phil, what about people taking fertility supplements when they have CKD?
Phil Webster
Well, if you mean vitamin tablets, many women will choose to take a vitamin, pregnancy vitamin before pregnancy and during pregnancy. Pregnant care is a common example and many supermarkets and pharmacies have got their own version of that and that's absolutely fine. I would say that critically, women really must take folic acid. That's not just women with kidney disease, but all women to reduce the risk of spinal cord development problems and that applies to our patients.
As you both know, many of our patients may have diabetes and in fact women with diabetes are recommended to take a higher dose of folic acid prior to pregnancy, the 5mg dose which is a prescribed rather than over the counter dose. And what's important is that folic acid is taken for ideally 3 months before conceiving.
Jeremy Levy
That's really helpful Phil, I hadn't realised it was quite so long but my memory of my children is a long time ago. Andrew, we also talked about herbal remedies didn't we in a previous episode which listeners should go and listen to because actually lots of people out there take herbal remedies and just to remember if patients, people have got CKD, chronic kidney disease, we really don't recommend using herbal remedies in general at all.
Andrew Frankel
Yes, absolutely, Jeremy. So, Phil, that was really helpful. But now let's move on to women we've known CKD who are planning a pregnancy. What advice do we need to give them before they get pregnant?
Phil Webster
So I co-lead a monthly pre-pregnancy counselling clinic where we do talk about these risks. And as we've already mentioned, and I think we do need to mention before I mentioned the risks, for women with early or mild kidney disease, the risks are low and many of these women, most of these women will go on to have successful pregnancies and healthy babies. However, we do treat all of these pregnancies at high risk so that these women can have the additional care that we want them to receive and also many of these pregnancies will require some timing and some planning which is why it's really important that we engage prior to pregnancy. I think the biggest risk that we discuss is of a condition called pre-eclampsia and this is where the placenta may either not develop or implant properly and this can lead to babies being small, small for gestational age or being preterm or very preterm and born early. And the worst case scenario if pre-eclampsia happens at an earlier stage of pregnancy is that baby doesn't survive or could be born with disability, but this is really quite rare.
Every woman unfortunately has a risk of pre-eclampsia and the risk in the general population is around 5 to 7%. Having underlying kidney disease and that includes having kidney disease with proteinuria, or chronic hypertension does increase the risk of pre-eclampsia. It's difficult to put a percentage on that, but again, the more advanced your kidney disease, the more uncontrolled your kidney disease, the higher the risk of pre-eclampsia. And unfortunately, in women with advanced kidney disease, maybe CKD, stage five, or women who are even on dialysis, that risk can be up to 50 % or more and so this makes it a very high risk pregnancy.
Jeremy Levy
Phil that was great but there's also a problem for the women and losing kidney function itself during pregnancy isn't there or am I remembering that wrong?
Phil Webster
That's completely correct, Jeremy. So pregnancy is a strain on kidney function. And so we do know that women with kidney disease who become pregnant might lose some kidney function. And sometimes that kidney function may not even recover postpartum. Again, this relates to your stage of CKD and your level of kidney function prior to pregnancy. And so broadly speaking, if a woman has mild CKD, which are... class as an eGFR before pregnancy of over 60 mls per minute, I would hope and anticipate that she would not lose any significant kidney function in a pregnancy. If a woman has pre-existing CKD stage 3a or 3b, so that's a GFR between 30 and 60, then we would estimate that whatever she may have lost in two years outside of pregnancy, she may lose that in a pregnancy.
And so that very much then relates to her trajectory of kidney decline prior to pregnancy. Unfortunately, women with advanced CKD, so a GFR less than 30 stages four and five, may lose kidney function more rapidly. They may lose up to five years of kidney function in a pregnancy. And they may even need to start dialysis in a pregnancy. So there can be really significant effect on kidney function in some cases.
Phil Webster
This means that it's really, really important that we are able to see these women in our specialist combined obstetric kidney clinic where they can have enhanced monitoring of their kidney function, their blood pressure, their symptoms, and also more growth scans of their baby. The final thing that I do speak to women about, and it's really important, are the medications they're on prior to pregnancy, because many of these may need adjustment. We do know that...
Drugs such as SGLT2 inhibitors and statins should be stopped prior to even trying to conceive because we do not have the evidence yet that these are safe in pregnancy. ACE's and ARB's, which are very common drugs in women with kidney disease and women with diabetes, are also not safe in pregnancy. But as we all know, Andrew and Jeremy, these drugs, ACE's and ARB's, can confer significant kidney protection, blood pressure control, and a reduction in proteinuria.
And so if a woman might take a longer time to get pregnant, she may not want to have a prolonged period of time off these kidney protective medications. So there's different ways that we can manage this, but if women are having regular menstrual periods and prepared to test for pregnancy regularly, and particularly if they are a day late for their period, then ACEs and ARBs can be continued up until the point of becoming pregnant and then stopped immediately when women are pregnant. If there's a chance that a woman may become pregnant and not realise, then we may need to manage this slightly differently and it may be that these drugs need to be stopped before she tries to conceive.
Andrew Frankel
So Phil, the key messages for me are that the risks are really very small if the GFR is over 60, mild when the GFR is 45 to 60, but then increasing but manageable with careful pregnancy care as the kidney function becomes more significantly poor and more severe CKD. And that these individuals are at risk not just of complications of the pregnancy itself, but of losing some of their kidney function and could be accelerated more quickly towards renal replacement therapy. And the key message also is to plan the pregnancy and plan the medicines management plan well before the patient becomes pregnant.
Phil Webster
That's completely right Andrew and I think one thing it's important to say is to go into pregnancy with blood pressure that's as optimised as possible and kidney disease that's been optimised as possible. We'd probably recommend a blood pressure target below 130 over 80.
If there's a reversible cause of kidney disease or a treatable cause, this should be treated and managed and optimised prior to pregnancy. And then there are some things that we can do within pregnancy to try to help manage some of these risks as well.
Jeremy Levy
That's been great. So shall we move on to that? That's clearly the next stage, isn't it? What about women with known CKD who then have got pregnant and clearly we want to manage them through the pregnancy and they'll often be seeing their GPs initially, which is of course who we're talking about here and we hope they might see specialist obstetricians as well. What are you advising women with known CKD who've now got pregnant?
Phil Webster
So, Jeremy, everything we've talked about so far is women who we may already have contact with, who are known to have kidney disease, and we'll talk about that very shortly. Obviously, pregnancy for many women may be their first contact with medical services. And so it's an opportunity for health promotion and we may pick up new kidney disease in pregnancy and these women do need to be referred into a nephrology and obstetric medicine service quite urgently because they need to have a diagnosis made. This kidney disease could impact a pregnancy and we may want to investigate and treat that really quite rapidly. But to go back to your original question in women with known kidney disease, we would want to see these women in our specialist clinic. We have a combined kidney obstetric clinic where the women and the babies can have enhanced monitoring.
Phil Webster
So for women with known CKD who are pregnant, they need very close monitoring during the pregnancy. We monitor their symptoms, we monitor their kidney function, their protein urea levels, their blood pressure, and many of the babies will need additional growth scans later on in the pregnancy to check fetal growth.
And we mustn't forget that in healthy kidneys, we would expect to see a fall in creatinine in pregnancy and a rise in GFR. EGFR is not validated in pregnancy, but it will still be reported and we'd see a fall in creatinine And research has shown that actually creatinine above 77 in pregnancy is abnormal and this should always be taken seriously and smaller perturbations in creatinine pregnancy can be significant.
Obviously we should have managed the medication prior to pregnancy but if this has not been already done then we need to modify medication. We offer all women with kidney disease and chronic hypertension, proteinuria or inflammatory conditions a low dose of aspirin which we usually start at around 12 weeks of the pregnancy, often around the time of their dating scan.
We supplement vitamin D in women during pregnancy. We've already mentioned that some women may take a pregnancy multivitamin and then there are some rarer conditions where medications like immunosuppression in our patients with kidney transplants or with autoimmune kidney disease need to be managed and monitored closely. Tacrolimus and azathioprine are safe in pregnancy. We have to measure tacrolimus levels more commonly. It's worth mentioning mycophenolate is absolutely not safe in pregnancy. It's teratogenic and should be stopped three months before trying to conceive.
Andrew Frankel
So really helpful information, For me, hearing that the creatinine above 77 is an abnormality in women who are pregnant is information I hadn't quite appreciated. And I want to just stress what you have stressed throughout, that all women with CKD need to be managed much more closely and they need more than just a routine midwife-led service.
Phil Webster
Absolutely. These women will have their standard care in pregnancy and we would also want them to have enhanced monitoring under an obstetric medicine clinic. Just to briefly mention the amazing maternal medicine networks where women can have local care delivered, we would absolutely want that to happen. But any woman who has more advanced CKD, so CKD 3 or above or heavier proteinuria with a PCR above 100 or uncontrolled kidney disease, we would absolutely want to look after them in a specialist kidney obstetric clinic and these women will need to see specialist midwives, obstetricians, obstetric medicine doctors and nephrologists.
Jeremy Levy
Phil, that's available across the UK or are we just very lucky to have you and colleagues in North West London.
Phil Webster
So these maternal medicine networks are rolled out across the UK and they have a hub centre for the more specialist care. The aim is to try to deliver this specialist care across all regions and all parts of the regions and within those maternal medicine networks there'll be a specialist clinic for the women with the more advanced end of disease and where they can have a combined clinic specialist care.
Jeremy Levy
Thanks, that's great. So you always bang on about this with us locally, Phil, and I think we should remind our audience that it's also really important to consider issues of contraception, isn't it, for women with CKD. It's important, clearly, if people want to get pregnant about pregnancy and contraception both before when we might be managing their kidney disease, but also after a successful pregnancy, as they might want to plan further pregnancies or not, as the case may be.
Phil Webster
Yeah, so really, really important and we're trying to ensure that this is brought up routinely in nephrology clinics as far as we can. So the best contraceptive is the LARCs. These are the long acting reversible contraceptives of which the Mirena is probably the most commonly known one. There's also the implant, the Implanon or the Nexplanon in women with kidney disease who are going to take a contraceptive pill, we usually recommend a progesterone only pill and it's also worth saying that condoms with normal human use really aren't as effective as people may think that they are and so we would usually recommend a contraceptive pill or a long-acting reversible contraceptive.
Jeremy Levy
That’s really helpful Phil. So progesterone only pills and the reversible implants are really useful. And just finally, we're going to just briefly mention some of course, kidney diseases are of course inherited, the classic one being polycystic kidney disease, but we know about lots of other ones. And so of course, couples business may affect men and women, may need very specific advice and counselling about the risks for their baby for inheriting a kidney disease. And we would never expect GPs to do this or to be able to do this unless they've acquired expertise. So these sorts of conversations really should be referred either to the couple's nephrologist or to an obstetric physician or medicine clinic, shouldn't they? Because this is often quite challenging conversation, really important to get right. Sorry. And the last point I'm going to add really just for information really, because we wouldn't expect GPs to be in the loop for this, but we are now able to get more and more women successfully through a pregnancy, even when they're on dialysis. Whereas 30 years ago, this was sort of thought near impossible. We're now seeing really quite a significant number of women on dialysis successfully achieving a birth. It is not straightforward and it is complicated, but certainly achievable now, isn't it?
Andrew Frankel
Phil, thank you so much for your contribution today. It's been brilliant. There's so many messages, but I'm going to highlight for primary care the three things that most stick out for me. Firstly, as you've said, that women and men with CKD can have fertility issues, but that is much more likely to occur with people with poorer kidney function, but most can still get pregnant. All women with CKD require good counselling before getting pregnant to plan their medicines, to plan their blood pressure optimisation, to be aware of the risks and the need for monitoring. But most of these can have successful outcomes. And that management in pregnancy itself, once someone with CKD becomes pregnant, requires much closer monitoring than for people, without CKD.
Jeremy Levy
Phil, that's been fantastically helpful. Thank you so much for joining us today.
Phil Webster
Thank you very much.
Jeremy Levy (23:56.506)
Well done Phil.
Pls Continue