pregnancy

The Kidney and Pregnancy


This is a particularly important topic because of the societal pressures and premium often given to having children, frequently at the risk of the life and health of the mother. This goal of this post is not to substitute for the professional services of the doctor/obstetrician who must be seen early and often during pregnancy but to empower patients during pregnancy so that they are aware of normal changes, possible issues that may arise involving the kidney, questions to ask their doctor and general best habits and practices to maintain kidney health during pregnancy.

Previously we have shared thoughts about pregnancy in dialysis and transplant patients. In this blog posts we will share our perspective on the issues that can arise and involve the kidney during pregnancy in patients with or without any known or prior kidney disease. To start the conversation, let’s talk about normal changes in the kidney and urinary tract during pregnancy before talking about what’s abnormal

The urinary bladder is pressed on by the uterus as it enlarges with the growing baby

In a normal pregnancy there are many changes in the kidneys and urinary tract that are not a sign of a problem but just a sign that the body is changing to accommodate the needs of the mother and growing baby

  • The increased blood volume and heart output during pregnancy causes about 50% increase in blood flow to the kidney. This causes an increased elimination of waste and reduced blood levels of urea, creatinine, urate and bicarbonate.
  • Mild amounts of glucose and/or protein in the urine may occur because the increase in blood supply to the kidney may exceed the ability of the kidney to reabsorb glucose and protein.
  • Pregnancy hormones increase the retention of salt and water by the kidney. This can cause leg swelling and reduction of concentration or plasma osmolality of the blood.
  • Pregnancy hormones also cause the smooth muscle of the urinary tract to become relaxed and dilated, kidneys increase in length and ureters become longer, more curved and with an increase in residual urine volume.
  • The increase in size of the womb or uterus presses on the bladder and reduces the space for the bladder to expand and store urine. So pregnant women often urinate often. Bladder smooth muscle however also relaxes, increasing capacity and risk of urinary tract infection
    2-10% of women have bacteria in the urinary tract during pregnancy and if untreated up to 30% may develop acute pyelonephritis- an infection of the kidneys which can be serious leading to problems like premature delivery and overwhelming infection of the mother

However, there are a number of changes that can arise involving the kidneys or urinary tract during pregnancy that are not normal. These problems include:

  1. Urinary tract infections. Sometimes there may be no symptoms to mild symptoms like frequent urination to more severe symptoms like fever, pain and bloodstream infection. At every visit and if you have any symptoms like those just mentioned, talk to your doctor, get tested for possible urine infection and get treated. There are several antibiotics that can be taken safely during pregnancy
  2. Blood in the urine (Also called Hematuria). 1 to 3 out of every 10 pregnant women will have hematuria at some point in pregnancy. 75% will resolve after delivery. Most common cause is vaginal bleed or urinary tract infection. Not always linked to increased risk of preeclampsia, hypertension or premature delivery. If you see blood in your urine, see your doctor, talk about what you see and how you feel. The doctor will likely get a urine test to make sure you don’t have a urine infection. The doctor may get an ultrasound of the kidneys and bladder to see of you have a kidney stone. Ultrasound scans are safe and pregnancy does not increase risk for kidney stones but if one is found, you likely had the stone before the pregnancy.
  3. Kidney disease during pregnancy. Kidney disease may preexist and be known, preexist and be discovered during pregnancy, or be new onset in pregnancy. Ability to sustain pregnancy depends on kidney function and blood pressure levels rather than the cause of kidney disease. Kidney function may decrease irreversibly during pregnancy and after delivery. Increased urinary protein excretion has worse outcome. Diabetes (high blood sugar), lupus, cystic kidney disease are all conditions that can worsen kidney function during pregnancy. Talk to your doctor about these so that a treatment plan can be developed to ensure you and your baby are safe.
  4. Hypertension in pregnancy. The kidney is an important organ in controlling blood pressure so it make sense that issues impacting the kidney can cause abnormal blood pressure in pregnancy. Hypertension affects 1 to 3 out of every 10 pregnancies. For hypertensive patients in pregnancy, most cases become hypertensive during pregnancy and this may continue after delivery. If you develop hypertension in pregnancy, you must be extremely careful, see your doctor and get the hypertension treated. There are several medications that can be used to treat high blood pressure in pregnancy safely. Hypertension can become a very serious condition called preeclampsia which can not only destroy the kidneys but lead to pregnancy loss, liver and even brain damage.

 

Questions

1. If I have kidney disease but I am not yet on dialysis, can I get pregnant? Yes it is possible. How easily you get pregnant depends on how severe your kidney disease is and the cause of your kidney disease. If you are a dialysis patient it is not impossible to get pregnant but it is a challenge and will require the skill of a kidney specialist that knows what to do working with your obstetrician

2. If I have kidney disease will it get worse if I try to get pregnant? It might get worse. You need to tell your doctor before you get pregnant if you already have kidney disease so the doctor can determine your risk of progressive or advanced kidney disease due to pregnancy. For some patients, the risk is too high and they may end up with kidney failure requiring dialysis or transplant after delivery. You may be advised not to become pregnant if your kidney disease is severe.

3. The doctor told me about doing a biopsy during the pregnancy to better understand why my kidney is having trouble. Should I do it? That decision is yours but ask to your doctor to describe the risks and benefits of the biopsy. If the benefit does not exceed the risk, you can decide to not do the biopsy or do it after the delivery.

Reproduction and Pregnancy- What men and women with kidney disease, on dialysis or with a kidney transplant should know


Having a child is a joy but conceiving or carrying a baby to term can be a challenge if you have medical problems. A question that likely crosses the mind of many patients of reproductive age, male or female is – “will i be able to have children?”. The good news is that many of the causes of reduced reproductive capability in patients with kidney disease are known and can be treated by carefully following the instructions of knowledgeable specialists in kidney disease and reproduction.

This post will aim to address the background behind reproductive potential of patients with kidney disease and answer questions of relevance to patients with either advanced kidney disease, those undergoing dialysis treatment or those who have a kidney transplant. The information in this post is NOT a substitute for close consultation with a kidney specialist and readers are advised to seek the counsel of such experts to address their care and concerns.

pregnancy-test-640x480

Getting pregnant can be a challenge even without having kidney disease. Sometimes, it may be safest if a woman does not get pregnant because the pregnancy may worsen the kidney disease or even lead to kidney failure requiring dialysis or transplantation or even death. Patients with a history of kidney disease in a prior pregnancy must be careful before getting pregnant again. With the right advice from doctors, it is possible to conceive and be successful with a pregnancy. Patients must however know that it will require a lot of resources to cover the costs of the more intensive care required.

Advanced kidney disease affects reproductive potential of both males and females and directly can impact the outcome of pregnancy.

In male patients with advanced kidney disease or on dialysis, problems with getting a sufficient erection, decreased sexual desire and decreased sperm count are common problems that make conception difficult. This is often due to low levels of male sex hormone called testosterone- a direct consequence of kidney disease. Getting close follow up with a doctor, getting anemia and hypertension treated properly and getting enough dialysis if necessary at least 3 times a week is key to addressing many of these problems.

Problems with erection and ejaculation however can occur in patients even without kidney disease. Diabetes (high blood sugar) is a common cause. Sometimes the medication used to treat high blood pressure may also cause problems with erection and need to be changed not stopped. Never stop your blood pressure medications because of erection problems or impotence. Talk to your doctor so the right blood pressure medication can be prescribed for you that does not have such side effects.

In female patients with advanced kidney disease there is often an absence of menses or abnormal menses, abnormal uterine bleeding and development of cysts in the ovary that disrupt the processes important for ovulation, fertilization, implantation and carrying the pregnancy to full term. It is estimated that only 1-2% of all patients with advanced kidney disease or on dialysis conceive. These chances improve significantly if you get proper care by a good kidney specialist. Only about half of those who conceive can carry their pregnancies to full term and in many cases the pregnancy is complicated by death of the baby in the womb, hypertension in the mother, premature labor and delivery, malformations in the baby and low birth weight of the baby.  For patients that are pregnant and already on dialysis, an increased dose and frequency of dialysis preferably on a daily basis is the best chance of successful outcome. It is recommended that pregnant dialysis patients undergo at least 20 hours or more of dialysis a week. The kidney specialist also needs to modify the  dialysis prescription to avoid bleeding by reducing the dose of blood thinner given during dialysis. Additional effort to control blood pressure and treat anemia is required. Nutrition is a big issue for pregnant dialysis patients and ensuring the pregnant mother gets enough vitamins including folic acid as well as protein is important. Pregnancy in a dialysis patient is a high risk pregnancy and care should be provided by both a kidney specialist and an obstetrician with experience caring for such patients.

It is important to note that for some women, kidney disease develops for the first time during pregnancy. Infections of the urinary tract need to be treated aggressively because they could lead to generalized infection and kidney failure or death. Some women develop severe  high blood pressure along with kidney and liver problems that can also be deadly.

Sexual problems for either men or women with kidney disease can be either physical or emotional. Emotional causes such as fear, anxiety and depression can seriously affect men and women equally and interfere with sexual intercourse, the ability to conceive or ability to carry a pregnancy to term. Healthy eating, exercise, talking to your partner about sexuality and health in an honest open way and following the doctors instructions are one of many ways to help deal with the emotional stress. For most patients, sexuality improves with the initiation of high quality frequent dialysis and gets even better after kidney transplant. Sometimes there may still be problems with sexual drive that persist even after transplant related to use of medications to prevent rejection or treat high blood pressure.

COMMON QUESTIONS ABOUT REPRODUCTION AND PREGNANCY IN KIDNEY DISEASE, DIALYSIS AND TRANSPLANT PATIENTS

Question: Is sexual intercourse safe for a patient with advanced kidney disease or patients on dialysis?

Answer: This is a common fear among such patients and there should be no such concern. Care should be taken to avoid damaging the dialysis access during sexual intercourse however.

Question: Is sexual intercourse safe for patients with a kidney transplant?

Answer: As long as the scar from the transplant surgery is fully healed, blood pressure is controlled and the doctor says it is safe to resume or start sexual activity, there should be no reason to worry about damage to the transplant kidney.

Question: What are the things that can affect a healthy pregnancy?

Answer: General health, age, presence or absence of high blood pressure, high blood sugar, or heart disease, presence of kidney disease.

Question: Can a woman with “mild” kidney disease have a baby?

Answer: Women with mild kidney disease with little or no protein in the urine can conceive and have a healthy pregnancy. Women with more severe kidney disease have a lower likelihood of getting pregnant and higher chance of serious complications during pregnancy which might lead to loss of the pregnancy, worsening of the kidney disease or both. If you have any degree of kidney disease and want to become pregnant, make sure you talk to a kidney specialist along with the doctor that will care for your pregnancy.

Question: Can a patient on dialysis have a baby?

Answer: It is possible but changes in the bodies of men and women on dialysis make it hard to either impregnate a woman or become impregnanted by a man. The risks to the mother and baby are quite high if a woman becomes pregnant on dialysis. If a woman becomes pregnant on dialysis, she will need close attention and very frequent dialysis to have a successful pregnancy.

Question: Can a kidney transplant patient have a baby?

Answer: Yes a woman with a kidney transplant can have a baby. However, it is usually recommended that such patients wait at least 1-2 years after the transplant with stable kidney transplant function before trying to become pregnant. There should be no protein in the urine and the dose of steroids should be at least 15 mg a day or less. Before you try to become pregnant, tell your doctor because in addition to the tests nneded to confirm it is safe to get pregnant, some of the medications used to prevent rejection of the transplant can affect the baby and need to be changed at least 6 weeks or more before any attempts to get pregnant. If the serum creatinine of a transplant patient is above a certain level, it is often recommended that the patient do not get pregnant in order to avoid the possibility of loosing the kidney transplant. Most pregnant kidney transplant patients will need to deliver by cesarean section although normal delivery has been reported. The obstetrician has to plan carefully on the surgical approach and has to consult with the nephrologist and if possible transplant surgeon to avoid damage to the transplant kidney during cesarean section surgery.

Men who have a transplant can father children. There may be some difficulty and if after trying for at least a year there is no success, you should seek the help of a fertility specialist and advice of your kidney doctor.

Question: What kind of birth control is recommended for patients with kidney disease?

Answer: Sometimes it is important to delay plans to become pregnant and birth control is needed. Women with kidney transplants or with high blood pressure should not use oral tablet or implanted hormonal contraceptives as these may increase the risk of rejection or deadly blood clots. These can also increase blood pressure and risk of events like stroke or heart attacks or heart failure. The safest options for birth control involve the use of condoms, diaphragms, sponges and the newer devices that can be placed in the uterus.