Chronic kidney disease (CKD) affects about 1 in 10 women worldwide, yet diagnosis is often delayed and women are less likely to receive critical treatments like dialysis or a kidney transplant compared to men, according to a new American Heart Association scientific statement recently published in the association’s flagship journal Circulation.
Eman Gohar, PhD, MS, Assistant Professor of Medicine in the Division of Nephrology and Hypertension, was the chair of the writing group that developed the scientific statement, “Women’s Kidney Health in Focus.” The writing group, with international representation from Canada and Europe, included nephrologists and kidney scientists as well as a transplant nephrologist and endocrinologist.
The scientific statement suggests improving women’s kidney care by recognizing how women’s unique biology and social factors affect kidney health and designing research that includes sex-specific analyses of kidney function and CKD medications.
“Many cases go undiagnosed in women because common tests and research do not always reflect women’s biology and life stages,” Gohar said. “Biological differences include genetics, sex chromosomes, hormones, immune-system responses and differences in how the body processes and responds to medication.
“We also need to acknowledge female-specific factors that do not apply in the same way to male patients. These include menstrual health, pregnancy, postpartum changes and menopause as well as socioeconomic factors like financial barriers or cultural expectations. Each of these creates considerations that are unique to women and may require tailored care.”
The scientific statement lists seven challenges women face in kidney care:
- Underrepresentation in clinical trials
- Less treatment access
- Delayed referrals
- Adverse pregnancy outcomes
- Menopause
- More adverse effects of kidney treatment medication
- Lower rates of kidney transplant
According to the statement, women may have different responses to kidney treatment medication compared to men but continue to remain underrepresented in clinical trials.
Women and men may respond differently to medications because of differences in how they are absorbed, distributed, broken down and removed from the body. Laboratory research points to estrogen receptors as having a potential role in women’s kidney function.
Kidney function is commonly estimated using creatinine, a waste product generated by muscle. Because women typically have less muscle mass and may produce less creatinine, these estimates may not always accurately reflect kidney function, thus causing kidney disease in some women to be misclassified or recognized later.
“Women are not simply smaller versions of men. Their biology, reproductive life stages and responses to medication may differ, and those differences need to be reflected in clinical care and research.”
Eman Gohar, PhD, MS
Understanding aspects of kidney health that are unique to women’s life stages is critical for advancing precision medicine.
“Kidney health and reproductive health are intertwined,” Gohar said. “Pregnancy, menstrual health and menopause may provide important information about a woman’s current and future kidney health.”
Pregnancy in women with CKD may increase the risk of kidney disease progression and pregnancy complications. Taking steps to manage blood pressure, blood sugar and body weight is suggested for women with CKD who plan to become pregnant.
In women without CKD, pregnancy complications such as preeclampsia may signal an increased risk of future kidney disease, heart disease and stroke.
Natural menopause before age 45 and surgical removal of the ovaries before age 50 are each linked with a higher risk of CKD. Other factors contributing to CKD after menopause include increases in obesity, type 2 diabetes and high cholesterol.
The statement suggests that embedding reproductive health assessment in CKD care is one step towards advancing precision kidney medicine.
In addition to pregnancy and menopause, other women-specific conditions affect CKD risk. Polycystic ovary syndrome, a common hormone disorder among women, and the autoimmune disease lupus, which is more common in women than men, are linked with a higher risk of CKD.
Women tend to begin dialysis at a lower level of kidney function compared to men, indicating a delay in treatment initiation. They are also less likely to receive a kidney transplant. Globally, men receive kidney transplants about 30% more often than women. In some low- and middle-income countries, the gap is more than 10-to-1.
Poverty, limited health literacy, caregiving responsibilities, cultural expectations, limited support and treatment costs may delay diagnosis or make specialist care harder to reach. These barriers may be especially serious in low-resource environments where access to kidney specialists, dialysis or transplant care is limited.
CKD is a major contributor to heart disease and stroke risk, which is why it is part of cardiovascular-kidney-metabolic (CKM) syndrome.
Diabetes, another part of CKM syndrome, is the leading cause of CKD worldwide. Among people with diabetes, some evidence suggests women may progress to kidney failure at higher rates than men.
The statement identifies research priorities that include enrolling enough women in clinical trials to determine whether treatments affect women and men differently, reporting results by sex and reproductive health-specific factors. Future research may help health care professionals detect kidney disease earlier and choose safer, more effective treatments.
“Women are not simply smaller versions of men,” Gohar said. “Their biology, reproductive life stages and responses to medication may differ, and those differences need to be reflected in clinical care and research.”
