For people living with chronic kidney disease (CKD), daily management of the condition is something that must be taken seriously at all times. CKD, due to many causes, means the kidneys do not function as well as they should, and they may get worse over time, with patients having to make lifestyle changes. If kidneys fail altogether, patients either need to have dialysis or a kidney transplant. Most patients with CKD will be on long term medications – to treat their underlying condition and also the complications of CKD, especially high blood pressure. People with CKD need to plan ahead, but where does this leave women who are considering having a baby? Is it safe to do so, and when is the best time? Leading consultant nephrologist, and expert in pregnancy and kidney disease, Professor Liz Lightstone answers these questions and more.
Previously, women with CKD would have been advised not to get pregnant due to the complications it can bring, but in recent times, as long as the woman and her doctor are aware of the kidney disease and plan ahead accordingly, then there is no reason why most women with CKD cannot go ahead and have a healthy pregnancy and a healthy baby.
Planning ahead for pregnancy and kidney disease
A woman’s kidney function is vital during pregnancy, and having CKD can cause a number of complications that need to be prepared for.
Because worse kidney function is associated with more problems for both the mother and the baby, if a woman has kidney disease that is leading to progressive loss of function, then doctors will often advise that opting for pregnancy sooner rather than later is better for the health of the mother and baby. In contrast, if they have a disease which flares, such as lupus, then that should be in remission for at least six months before getting pregnant. Some forms of contraception are not suitable for women with CKD, but the progesterone-only pill, or implant or coil (Mirena) are all fine. Whilst barrier methods are recommended to avoid sexually transmitted disease, they have a very high failure rate and should not be relied upon on their own.
Another factor women with CKD need to be aware of is that chronic kidney disease can increase the risk of pre-eclampsia, a pregnancy complication that can occur after 20 weeks of pregnancy, and which requires delivery to treat it so can lead to premature birth of a baby. The symptoms of pre-eclampsia include high blood pressure, excess protein in the urine, severe headaches, nausea, abdominal pain, and shortness of breath. A woman who is pregnant and has CKD should be prepared for the risk of pre-eclampsia and recognise the signs early in order to get effective treatment. Low dose aspirin given no later than 12 weeks of pregnancy reduces the risk.
Giving birth with CKD
Once a woman with chronic kidney disease is pregnant, preparations should be made for the birth. A hospital with specialists in obstetrics and neonatal care, along with kidney specialists should be chosen.
Whilst most women with CKD, even kidney transplants, can plan to have a normal vaginal delivery, sometimes it may be necessary for a woman with CKD to have a caesarean section, particularly if they have early pre-eclampsia.
CKD medication and pregnancy
Some medications prescribed for chronic kidney disease, should not be taken during pregnancy. Immunosuppressants such as cyclophosphamide, methotrexate, mycophenolate, are among the medications that must be avoided during pregnancy, particularly at conception and in the first trimester. Rituximab and belimumab should also generally be avoided if possible. Women that are using these medications should make changes well in advance of getting pregnant, to allow the body to get used to the change in medication and to ensure there are no unwanted side-effects.
A specialist can advise on the changes of medication to make. Importantly prednisolone, azathioprine, tacrolimus, hydroxychloroquine and low dose aspirin are all fine and should be continued. Some blood pressure medications will need to be changed either before or in early pregnancy. ACE inhibitors (e.g. enalapril, Ramipril) and angiotensin receptor blockers (e.g. losartan, irbesartan) must not be taken once a woman knows she’s pregnant and absolutely not in the second and third trimester.
Pregnancy following kidney transplantation
Fertility declines with poor kidney function but is restored rapidly with a well-functioning kidney transplant. Women should wait at least a year after transplantation before trying to conceive and again, should discuss their plans well in advance with their kidney specialist to ensure safe medication.
Kidney dialysis and pregnancy
The fertility of women on regular haemodialysis can be increased by increasing the amount of dialysis. Importantly, if a woman on dialysis does become pregnant, her and the baby’s outcomes are greatly improved if dialysis frequency is increased to almost daily and with longer hours. Such pregnancies absolutely must be managed in centres with kidney specialists, obstetricians with expertise in the management of high-risk pregnancies and a neonatal intensive care.
All women planning pregnancy should aim to optimise their weight, stop smoking and take folic acid before trying to conceive.
If you have chronic kidney disease, and are considering getting pregnant, make an appointment to see a specialist and ensure you have all of the necessary preparations in place.