Kidney Disease and Women
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 ofCKD in India is not clear but studies estimate that the number of new patientsdiagnosed with End Stage Kidney Disease (ESKD) who are started on dialysis ortransplantation is over 100,000 per year. This number likely grosslyunderestimates the true burden of kidney disease in our country given theinequality in access to health care between urban and rural populations and dueto disparities in wealth and literacy.
Aside from these general population based issues, there are uniquemedical and socio-economic challenges faced by women which are essential tounderstand in order to improve their access to kidney care and therefore theiroverall health.
The most common causes of kidney disease in India in both men andwomen are Diabetes and Hypertension. However, there are certainconditions affecting the kidneys that occur with a greater incidence in women –for example urinary tract infections that lead to infection and scarring of thekidneys and autoimmune diseases Rheumatoid Arthritis and Systemic LupusErythematous. Early detection and treatment of these conditions isessential for good kidney outcomes.
Chronic kidney disease can negatively impact a woman’s fertility and insome cases, the medication used to treat certain kidney diseases can have thesame effect. Therefore, medications have to be carefully selected forwomen of child-bearing age. Pregnancy in itself carries risks for boththe 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 worseningof CKD in the mother as well as prematurity and low birth weight in thebaby. These conditions may actually increase the risk of future kidneyproblems in the new-born.
Advancements in our understanding of pregnancy and kidney diseaseshowever, have allowed substantial improvements in outcomes of pregnanciesamongst patients even with ESKD who require dialysis or are transplanted. Once again, access to pre-conception primary care to detect baseline kidneyproblems, and access to good prenatal and antenatal care is essential.
Once a patient reaches advanced stages of CKD, kidney replacementtherapy will be needed. Kidney replacement therapy can be either dialysisor kidney transplantation; with transplantation offering the best healthoutcomes. Studies indicate that women tend to have more complicationswith dialysis than men; as an example the incidence of low blood counts andpoor nutritional levels seem to be higher.
They may fare just as well as their male counterparts post kidneytransplantation. However, interestingly the number of male patients whoreceive either dialysis or kidney transplantation is significantly greater thanwomen. Studies from countries all over the world, including India,indicate an inequality in the registration of women on deceased organ donationwaiting lists and longer waiting times for women on dialysis. Globallyand in India, women tend to serve more often as kidney donors - mothers andwives are much more likely to be donors than fathers or husbands.
The recurring theme here, seems to be timely access to kidneycare. And clearly, there is substantial inequality in access to carebetween the genders. What may be the underlying factors for thisinequality? Social-economic, educational and psychological factors areall likely in play.
Specific gender roles are still very clearly defined in India. Women inour country today, still have less access to education and therefore tend to bemore financially dependent on men. In the majority of the families, menmay be the sole or major bread-winners. The family’s need to keep a malemember with CKD in the work-force may be a strong factor impacting the higherlikelihood of women serving as donors.
As such, a woman may be donating due to a feeling of obligation or undercoercion from the male patient or other family members. Donor andrecipient pairs undergoing transplant evaluation do have to meet with apsychiatrist who will help assess these psychosocial issues, however, given thestrong cultural and financial factors some families face in India, these casesare complex.
For the working woman with a family, an underlying chronic medicalproblem such as End Stage Kidney Disease, which requires the time commitmentdemanded by regular dialysis or kidney transplant planning, recovery and followup, can be a major challenge. The additional stigma in traditional Indiansociety of the young unmarried woman with a chronic medical condition thatcarries a financial burden and impacts fertility and pregnancy cansignificantly affect her marriage prospects and therefore future family life.
The annual World Kidney Day campaign allows us to assess where we aretoday with kidney health across the globe. This year’s theme of women’shealth has focused our attention on the specific difficulties faced by thissegment of the population. There are medical aspects to consider – certainkidney conditions disproportionately impact women, pregnancy and the health ofthe unborn child; and there are complex socio-economic, psychological andcultural aspects to consider in our country.
Advancements in medicine, more awareness and a greater impetus onthe part of the medical fraternity and government to increase access to healthcare for women will pave way for better outcomes in the future.