Implications of Antiabortion Laws on Patients with Kidney Disease in Pregnancy

Pregnancy in people with kidney disease is high risk, requiring careful and deliberate multidisciplinary counseling and monitoring. Advanced kidney disease, possible flare of underlying systemic disease, and use of teratogenic medications may lead to significant risks to mother and fetus in pregnancy and may lead to permanent worsening of kidney disease.1 This propensity for high maternal and/or fetal risk requires shared reproductive decision making between a patient with kidney disease and their nephrologist. The June 2022 Supreme Court decision in Dobbs vs Jackson Women's Health Organization will limit abortion and reproductive care for many pregnant patients with kidney disease. This change will restrict access to reproductive health care, which may increase maternal and fetal morbidity and mortality and exacerbate existing health care disparities in our country. Risks of Pregnancy for People with Kidney Disease Advanced CKD affects 1:150 people of reproductive age and 1:750 pregnancies.2 Any maternal CKD is associated with a higher risk of adverse pregnancy outcomes with risks compounded by advanced CKD stage, hypertension, proteinuria, and other comorbidities.1 Risks to the fetus include prematurity, fetal growth restriction, and neonatal intensive care admission; these risks worsen considerably with advancing CKD stage.3 Maternal risks include fetal loss, preeclampsia, preterm delivery, and cesarean section. The risk of preeclampsia is higher with advanced CKD, affecting 18%–67% of people on dialysis and 25%–35% of transplanted people.1 Pregnancy carries a substantial risk of worsening kidney disease: 20% of people with advanced CKD (stages 4 or 5) who become pregnant experience a worsening of eGFR or need to initiate KRT, which confers a greater mortality risk over time.3 Overall, pregnancy in people with kidney disease is high risk, which necessitates careful shared reproductive decision making. Careful shared decision making regarding medications for kidney disease is crucial for people with kidney disease who are considering pregnancy. Treatment of kidney disease—including CKD treatment, transplantation, and immunosuppression for multiple glomerular diseases, such as lupus nephritis—involves the use of teratogenic medications. For example, angiotensin-converting enzyme inhibitors are associated with a higher risk of fetal renal dysplasia, fetal growth restriction (FGR), oligohydramnios, and fetal death. In transplant recipients, the use of induction medications and some maintenance immunosuppressants are also associated with adverse pregnancy outcomes. Despite these risks, people of reproductive age often do not receive adequate counseling regarding these medications: In one study, 75% of participants identifying as women of reproductive age in a nephrology clinic were on a teratogenic medication, but only 28% were on contraceptives4 and 41% of these patients had no documentation of any reproductive counseling.4 Thus, an ill-timed pregnancy can result in disease progression or flare, and teratogenic medication exposure with serious consequences to the unborn child. These potential consequences for people with kidney disease who are considering pregnancy require confrontation of uncertainties regarding progression of kidney disease and worsening of their own health. Many patients with kidney disease desiring pregnancy describe having to rationalize risk with the competing priorities of their own survival or harm to the fetus. Participants identifying as women of reproductive age with CKD describe an immense sense of loss around childbearing, anxiety of waiting for kidney deterioration to be eligible for kidney transplant, fears of exposing children to potentially harmful medications, and feelings of guilt to their partner, child, and transplant donor.5 Many participants expressed a loss of control and ownership of decision making, yet felt pregnancy was a personal decision that they owned.5 These participants urged for improved comprehensive, balanced information and health education that considered their personal preferences and goals, and most importantly, they felt they should be centered in the decision-making process.5 The Effect of Restrictive Abortion Policies on People with Kidney Disease Policies that limit bodily autonomy are associated with adverse reproductive health outcomes.6 States with restrictive abortion policies have a higher likelihood of pregnancy continuation, but there is also an greater maternal morbidity and mortality. One in eight people seeking an abortion report a health-related concern as their primary reason for ending their pregnancy.7 People with kidney disease who cannot access abortion will be forced to carry a pregnancy to term, risking their health and the health of their future child. It is for this reason that the American Society of Nephrology and the American Society of Transplantation both denounced the decision in Dobbs vs Jackson Women's Health Organization, stating that “given the high rate of preventable pregnancy-related deaths for people with underlying medical conditions, pregnancy-related decisions must be made between patients and their physicians.”8 Access to safe abortion care may be limited through numerous state policies such as gestational age limits, ultrasound requirements, mandatory counseling, waiting periods, insurance coverage limitations, and targeted regulations on abortion providers. Currently, 43 states have some form of gestational age limits, 24 require a preabortion waiting period, and 17 require preabortion counseling.9 As of October 7, 2022, 13 states have full abortion bans, one state has a 6-week gestational limit, and four additional states have gestational limits ranging from 15 to 20 weeks.9 Exemptions for an emergency condition, such as to save a pregnant person's life, are not universal. Many of these policies do not consider multiple complications faced by people with kidney disease. Many pregnancies in patients with CKD are unplanned due to low use of contraception and inadequate counseling on fertility these patients receive. Given that many patients with CKD may discover their pregnancy after 6 weeks, gestational bans below 6 weeks of gestation risks potential irreversible harm to the fetus due to teratogenic medication effects taken by many patients with CKD. Furthermore, shared and informed decision making regarding pregnancy risks may not take place until after 6 weeks, which may lead to maternal and fetal complications without access to abortion. Antiabortion laws will limit comprehensive clinician-patient counseling and access to reproductive care. In Texas, where abortion has been limited to 6 weeks of gestation or less since September 2021 (and now is fully banned), many clinicians caring for complex pregnancies did not counsel patients on their options for termination due to fear of legal repercussion.10 Black and Latinx populations are more likely to develop kidney disease and are less likely to have nephrology care, which is essential to adequate reproductive counseling. These same groups have higher rates of unintended pregnancy, are more likely to seek abortions, and are more likely to experience pregnancy-related complications and adverse maternal outcomes.11 These disparities, in both maternal health and kidney disease, are caused by systemic inequities including limited access to care, higher rates of discrimination and resulting allostatic load, and environmental risk factors.11 In the post-Roe vs Wade era, these populations are more likely to live in states with antiabortion laws and face more structural barriers to abortion access due to lower access to health care and lack of financial resources. People unable to access abortion are more likely to face poverty, financial debt, and lower credit scores than those who receive abortions.7 In addition to higher risk of adverse maternal and fetal outcomes should a pregnancy continue, people seeking abortion with limited health care access and/or financial resources are less likely to have access to a medically safe procedure and more likely to suffer a deleterious consequence, including septic abortions and AKI. Antiabortion laws thus propagate systemic inequities by disproportionately affecting vulnerable populations including Black and Latinx groups, as well as those of lower socioeconomic status. Practice Recommendations Now more than ever, it is the obligation of the nephrologist, along with multidisciplinary teams caring for patients with kidney disease, to provide early and thorough reproductive counseling to patients with kidney disease who may become pregnant through the following means: Reproductive decisions should be discussed early before pregnancy. Nephrologists must be familiar with contraceptive options for people with kidney disease, as some contraception options may be associated with changes in blood pressure, proteinuria, and kidney disease progression. Counseling regarding timing of pregnancy in relation to eGFR decline, dialysis needs, and/or medication changes are essential in pre-pregnancy counseling to avoiding an ill-timed pregnancy. Multidisciplinary kidney obstetrics teams should follow these patients to provide preconception counseling and manage teratogenic medications before pregnancy, and create comprehensive, multidisciplinary care plans for pregnancy, delivery, and the postpartum period. Nephrologists must outline all obstetric risks associated with medications and pregnancy timing during pregnancy counseling. Especially in states with restrictive abortion laws, understanding these laws and adapting earlier and comprehensive contraceptive, fertility, and risk management approaches are crucial. Care delivery should be tailored to the patient's preferences, especially considering that counseling without knowledge of these values can impede informed decision making. During pregnancy, nephrologists must play an active role to avoid deleterious outcomes via active management of proteinuria, hypertension, and dialysis treatments. Relevant social determinants of health affecting pregnancy, such as insurance status, health care access, health literacy, and cultural norms, should be addressed throughout pregnancy counseling and during pregnancy. This is especially crucial for vulnerable populations including Black and Latinx groups, as well as people of low socioeconomic status, who are more likely to be affected by kidney disease and adverse maternal/fetal outcomes and less likely to receive adequate nephrology and reproductive care. Finally, it is imperative that nephrologists become active advocates for policies allowing for full and informed reproductive care for all kidney disease patients and allowing for the provision of safe, patient-centered care, especially in situations that risk significant maternal and fetal health.