World Kidney Day 2018: Reflections on women and chronic kidney disease

March 8th this year, coincidentally marks two important global campaigns – International Women’s Day and World Kidney Day. The theme, therefore, ascribed to this year’s World Kidney Day is the burden and impact of kidney disease on women. Chronic Kidney Disease (CKD – when the damage to the kidneys is irreversible) affects about 10% of the world’s population.

Due to the lack of accurate national data collection, the incidence of CKD in India is not clear but studies estimate that the number of new patients diagnosed with End Stage Kidney Disease (ESKD) who are started on dialysis or transplantation is over 100,000 per year. This number likely grossly underestimates the true burden of kidney disease in our country given the inequality in access to health care between urban and rural populations and due to disparities in wealth and literacy.

Aside from these general population based issues, there are unique medical and socio-economic challenges faced by women which are essential to understand in order to improve their access to kidney care and therefore their overall health.

The most common causes of kidney disease in India in both men and women are Diabetes and Hypertension. However, there are certain conditions affecting the kidneys that occur with a greater incidence in women – for example urinary tract infections that lead to infection and scarring of the kidneys and autoimmune diseases Rheumatoid Arthritis and Systemic Lupus Erythematous. Early detection and treatment of these conditions is essential for good kidney outcomes.

Chronic kidney disease can negatively impact a woman’s fertility and in some cases, the medication used to treat certain kidney diseases can have the same effect. Therefore, medications have to be carefully selected for women of child-bearing age. Pregnancy in itself carries risks for both the woman with CKD and her unborn child.

These risks, which increase in more advanced stages of kidney disease, include severe high blood pressure, protein losses in the urine, and worsening of CKD in the mother as well as prematurity and low birth weight in the baby. These conditions may actually increase the risk of future kidney problems in the new-born.

Advancements in our understanding of pregnancy and kidney diseases however, have allowed substantial improvements in outcomes of pregnancies amongst patients even with ESKD who require dialysis or are transplanted. Once again, access to pre-conception primary care to detect baseline kidney problems, and access to good prenatal and antenatal care is essential.

Once a patient reaches advanced stages of CKD, kidney replacement therapy will be needed. Kidney replacement therapy can be either dialysis or kidney transplantation; with transplantation offering the best health outcomes. Studies indicate that women tend to have more complications with dialysis than men; as an example the incidence of low blood counts and poor nutritional levels seem to be higher.

They may fare just as well as their male counterparts post kidney transplantation. However, interestingly the number of male patients who receive either dialysis or kidney transplantation is significantly greater than women. Studies from countries all over the world, including India, indicate an inequality in the registration of women on deceased organ donation waiting lists and longer waiting times for women on dialysis. Globally and in India, women tend to serve more often as kidney donors – mothers and wives are much more likely to be donors than fathers or husbands.

The recurring theme here, seems to be timely access to kidney care. And clearly, there is substantial inequality in access to care between the genders. What may be the underlying factors for this inequality? Social-economic, educational and psychological factors are all likely in play.

Specific gender roles are still very clearly defined in India. Women in our country today, still have less access to education and therefore tend to be more financially dependent on men. In the majority of the families, men may be the sole or major bread-winners. The family’s need to keep a male member with CKD in the work-force may be a strong factor impacting the higher likelihood of women serving as donors.

As such, a woman may be donating due to a feeling of obligation or under coercion from the male patient or other family members. Donor and recipient pairs undergoing transplant evaluation do have to meet with a psychiatrist who will help assess these psychosocial issues, however, given the strong cultural and financial factors some families face in India, these cases are complex.

For the working woman with a family, an underlying chronic medical problem such as End Stage Kidney Disease, which requires the time commitment demanded by regular dialysis or kidney transplant planning, recovery and follow up, can be a major challenge. The additional stigma in traditional Indian society of the young unmarried woman with a chronic medical condition that carries a financial burden and impacts fertility and pregnancy can significantly affect her marriage prospects and therefore future family life.

The annual World Kidney Day campaign allows us to assess where we are today with kidney health across the globe. This year’s theme of women’s health has focused our attention on the specific difficulties faced by this segment of the population. There are medical aspects to consider – certain kidney conditions disproportionately impact women, pregnancy and the health of the unborn child; and there are complex socio-economic, psychological and cultural aspects to consider in our country.

Advancements in medicine, more awareness and a greater impetus on the part of the medical fraternity and government to increase access to health care for women will pave way for better outcomes in the future.