How do I prescribe contraception in patients with kidney disease or status post kidney transplant?

Written by: Husam Alzayer MD

AcademicCME (www.academiccme.com) is accrediting this educational activity for CE and CME for clinician learners. Please go to https://academiccme.com/kicr_blogposts/ to claim credit for participation.

Pregnancy rates have improved across all stages of chronic kidney disease (CKD). However, pregnancy and fetal outcomes remain worse than their age-matched controls, with significant concerns regarding kidney disease progression. While nephrologists do not usually discuss fertility-related matters, they commonly prescribe teratogenic medications, which can further increase fetal risk. In a UK cohort of kidney transplant recipients, most pregnancies (>90%) are unplanned post-transplantation, with less than half (48%) receiving proper counseling, emphasizing the need for proactive planning and early intervention. Safe and effective contraception methods should be offered to all patients with CKD and transplant recipients. This blog post is part of the (Kidney Care in Pregnancy) series and focuses on contraception in kidney disease and transplantation. Make sure to read the other blog posts and check out this tweetorial about contraception in CKD.

Contraception methods

Contraception methods can be grouped into four categories based on their effectiveness with typical use (failure rate):

• Very effective (0–0.9%)

  • Intrauterine devices (0.2-0.8%), subdermal implant (0.05%), and permanent sterilization (0.02-0.5%)

• Effective (1–9%)

  • Injectable contraceptives (6%), combined hormonal contraceptives (9%), and progestin-only pills (9%)

• Moderately effective

  • Barrier method (18%): condoms, caps, sponges, and diaphragms

• Least effective

  • Fertility awareness method (20%), withdrawal (22%), and spermicides

Figure 1. Very effective contraception methods. Images adapted from inviTRA™

Figure 2. Effective contraception methods. Images adapted from inviTRA™

Figure 3. Moderately effective contraception methods. Images adapted from inviTRA™ and iStock.

Table 1. Contraception failure rate adapted from Klein et al. 2022

Cu, copper; IUD, intrauterine device; LNG, levonorgestrel; DMPA, depot medroxyprogesterone acetate; POP, progestin-only pill; CHC, combined hormonal contraception (oral contraceptive pills, transdermal patch, vaginal ring); STD, sexually transmitted disease; BMI, body mass index.

Contraception and kidney disease

All patients with CKD of childbearing age should receive reproductive counseling regardless of their stage. Patients who do not wish to conceive, are at significant risk of disease progression, or are using teratogenic medications should use safe and effective contraception methods as detailed above. Any contraception method should be driven by the patient's needs, lifestyle, and comorbidities. It is preferred that patients on mycophenolate use two reliable contraception methods.

There should be careful consideration in using an estrogen-containing contraception pill due to its risk of inducing or worsening proteinuria, and patients with CKD tend to have absolute contraindications to their use, such as:

• History of venous thromboembolism

• Cardiovascular disease

• Breast cancer

• Impaired liver function

• Active smoking in a woman older than 35 years

Relative contraindications include:

• Systemic lupus erythematosus

• Diabetes mellitus

• Hypertension

• Hypertriglyceridemia

Contraception and kidney transplant recipients

Reproductive counseling should start before transplantation and continue soon afterward with repeated discussions during follow-up visits for patients of childbearing age. Counseling should include the proper use of contraception methods and educating patients on reproductive options and necessary medication changes to minimize pregnancy risk on the mother, fetus, and graft.

Kidney transplant recipients are advised to use two reliable contraception methods, with consistent condom use being one of them. The choice of a contraception method should be tailored to the patient's needs, lifestyle, and comorbidities. The CDC contraception recommendations subdivide transplant recipients into those with stable vs. complicated graft function (acute or chronic graft failure or rejection). All hormonal contraception is considered safe in patients with stable function. However, combined hormonal contraception is not recommended with complicated grafts along with the consideration for its absolute and relative contraindications. Intrauterine devices (IUD) are considered a safe method of contraception, but there have been case reports of pregnancies while using a copper IUD. However, levonorgestrel IUD appears to be both safe and effective.

Conclusion

Early and proactive reproductive counseling are essential to caring for female patients with kidney diseases. Choosing contraception should be tailored to the patient's needs, lifestyle, and comorbidities. Physicians should carefully consider the contraindications of using estrogen-containing contraception. Using two reliable contraception methods in kidney transplant recipients and patients receiving mycophenolate is advised.

Reviewed by: Sophia Ambruso, DO

AcademicCME (www.academiccme.com) is accrediting this educational activity for CE and CME for clinician learners. Please go to https://academiccme.com/kicr_blogposts/ to claim credit for participation.