Thread by @SRameshMD

🚨Tweetorial alert🚨
Contraception in patients with kidney disease

🆘 Help! I have a woman of reproductive age in my office for contraception advice!

25-year-old with stage III CKD (eGFR 42) due to reflux nephropathy.

How comfortable are you with providing advice?

Does CKD impact the type of birth control a patient can safely use?

Why does it matter?

Only 37% and 27% of respondents in the US and Canada are confident or very confident about contraception counselling - @emhendren’s study mdpi.com/2077-0383/8/2/…

But prevalence of CKD and CKD in women is increasing (1.29xmen)
thelancet.com/article/S0140-…

Not to mention...

Nephrologists often prescribe teratogenic medications, and effective contraceptive options should be provided

Pregnancy in CKD = ⬆ maternal and fetal risks

Patients with kidney transplants have restored fertility

nature.com/articles/nrnep…

Before we start...

Below is a non-exhaustive list of different options-ranging from spermicides first used in ancient Egypt to the recently introduced subdermal implants

Contraception methods are wide ranging and continue to evolve

How efficacious are these modalities?

>99% effective - implant, IUD, vasectomy/tubal ligation

88%-94% effective - injectable, pill, patch, ring, diaphragm

>82% effective - other barrier methods, fertility awareness

In patients with CKD, which hormonal contraception option is preferred?

(Discussion of each option below)

Estrogen+progestin (pill/patch/vaginal ring)

⬆VTE- implication in vasculitides and nephrotic syndrome
⬆BP, filtration fraction+ renal vascular resistance
⬆microalbuminuria w/ odds ratio of 1.90(1.23-2.93) in case-control study

obgyn.onlinelibrary.wiley.com/doi/10.1002/ij…
jamanetwork.com/journals/jamai…

Progestin only

💊oral form
-no risk of VTE
-drospirenone theoretical risk of ⬆K due to antimineralocorticoid effect

💉 IM form
-small risk of VTE
-risk of ⬇bone density (reversible) 0.5-3.5% BMD loss @ 1yr

acog.org/clinical/clini…

IUD/Implant

Progestin only IUD and subdermal implants carry no VTE risks but have benefits (higher efficacy, higher continuation rates, and higher satisfaction rates) in those who desire long term protection

Recommended as first line contraception

Considerations for IUD (progestin/copper)

- Case reports of PD peritonitis w/ insertion in patients on PD
- Old case report of ⬇️ effectiveness in women with renal transplant. Disputed by observational studies

europepmc.org/article/med/70… .
ncbi.nlm.nih.gov/pmc/articles/P…

Non-hormonal

Barrier methods- great option for pts who cannot be on hormonal contraception

Surgical sterilization- great permanent option

Tracking ovulation and avoiding intercourse - ⚠️not recommended- 73% of women with CKD will have irregular menses

ackdjournal.org/article/S1548-…

Special populations of renal disease

Patients on antimetabolites- encouraged to have 2 forms of birth control given use of teratogenic medications

Transplant recipients- fertility is often restored post-transplant. Recommend delaying pregnancy at least 1 year post-transplant

So which to pick?

Each option has benefits and risks
-Good evidence- Avoid combined OCP if high risk of VTE or nephrotic syndrome
-Moderate evidence- decrease in BMD with IM progestin
-Poor evidence- case reports of peritonitis in PD pts w/ IUD insertion

acog.org/clinical/clini…

Below are (a few) resources for further information - thanks to @mala_sachdeva @SofiaAhmedMD @anna_burgner and @SinReni

ajkd.org/article/S0272-…

ackdjournal.org/article/S1548-…

seminarsinnephrology.org/article/S0270-…

link.springer.com/article/10.100…

Thanks #NSMCinternship! Co-members of the bean pod @brian_rifkin @dr_missyhanna @elliotktannor @nephromythri @jadav_md @SaiAchi1 @lama_ghazi @hellokidneyMD. Mentors - @amyaimei @nephrosparks @docanjuyadav @SwastiThinks @sophia_kidney
Special thanks to @emhendren for this idea!