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On June 24, 2022, the US Supreme Court overturned precedent established by Roe v Wade in 1973 and Planned Parenthood v Casey in 1992, which eliminated the constitutional right to abortion. In the wake of this decision, individual state laws govern the legality of abortion. Thirteen states have “trigger” laws that ban abortion at a specified time after the overturning of Roe, and another 7 states have pre-Roe laws banning abortion that remain on the books but have not been enforced since 1973.
Access to abortion is particularly salient for those with chronic kidney disease (CKD), whose health and childbearing experiences are more nuanced than these laws can acknowledge. Owing to an altered hypothalamic-pituitary-ovarian axis, erratic menstrual cycles are common in people with CKD
Exemptions in instances where abortion will save a pregnant person’s life or preserve health are heterogeneously applied across states, and in some states exemptions do not exist. In Missouri, abortion is now banned “except in cases of medical emergency.”
Analysis by the Guttmacher Institute details that exceptions for health have generally permitted abortion in instances of “substantial and irreversible impairment” or “imminent peril” of a “major bodily function.” In such cases, it is the physician’s responsibility to prove this.
In this post-Roe era, where and by whom will the line be drawn between health and life for pregnant people with CKD to justify an exception? Is a patient with a severe lupus nephritis flare at 14 weeks’ gestation, for whom termination of pregnancy would facilitate more treatment options, in “imminent peril”? Does accelerating the need for dialysis by several years in a patient with CKD stage 4 constitute “substantial and irreversible impairment”? When a pregnant patient on dialysis is advised that optimal pregnancy care would include increasing to 36 hours per week of hemodialysis, straining their ability to work or care for other children at home, is this sufficient disruption of “bodily function?” For our patients, these decisions influence not only their health, but their functionality and livelihoods. Each person with CKD deserves the right to draw their own, highly personal line, weighing the risks and benefits of continuing a pregnancy. To support patients in their reproductive goals, it is imperative that nephrologists become familiar with our state laws, which may evolve, so that we may advise our patients about the safest available treatment options and nearest resources.
Historically, pregnancy was discouraged in people with CKD owing to risks of maternal morbidity, death, and poor fetal outcomes. With advancing neonatal care, more recent evidence suggests that live birth rates have improved for people with CKD and that risks are decreased when pregnancies are well planned with optimized preconception blood pressure and disease stability on a regimen of pregnancy-compatible medications.
However, timing a pregnancy in the context of one’s kidney disease, whether it may be progressive or relapsing and remitting, as well as the myriad other personal, relational, social, and economic factors that influence family planning, is not always straightforward. Family planning challenges specific to CKD, as well as downstream challenges in pregnancy, now exacerbated by restricted abortion access, are summarized in Fig 1. Options for reliable contraception may be medically limited for some people with CKD, owing to the potential cardiovascular risks of estrogen-containing contraception,
—2 of the most vulnerable populations to a high-risk, unplanned pregnancy. For those with a kidney transplant, conceiving while taking standard-of-care maintenance immunosuppression with mycophenolate mofetil increases the risk of spontaneous abortion and congenital malformations.
Although risk is inherent in all pregnancies, it is particularly elevated in those with underlying CKD. The United States currently has the highest maternal mortality rate in the industrialized world and each year roughly 700 women die owing to pregnancy or delivery complications.
In addition, pregnancy-associated progression of CKD was reported to occur in 80% of individuals who experienced pregnancy with a preconception estimated glomerular filtration rate of <60 mL/min/1.73 m2.
Although CKD progression may not immediately threaten one’s life in pregnancy, it certainly affects health and can decrease longevity across a lifespan. These risks will be compounded in marginalized communities that are disproportionately impacted by the lack of access to abortion services owing to systemic inequities.
Neither medical nor surgical abortions are medically contraindicated in kidney disease. Access to legal, medically supervised abortion procedures reduces the immediate morbidity and mortality of unsafe abortion procedures.
In a cohort study, those who were turned away from wanted abortions were more likely to report a persistent worsening in self-rated health 5 years later compared to those who received first- or second-trimester abortions.
an outcome closely linked to long-term cardiovascular health. As procedural abortion access is further restricted, more pregnant people will likely turn to self-managed abortions. As nephrologists, we must equip ourselves with resources so that when a pregnant patient desires an abortion, we can guide them away from life-threatening techniques and connect them to medical management with mifepristone and misoprostol, where available.
The juxtaposition of the desire for pregnancy and the burden of managing a chronic disease is challenging for people with CKD.
The risks of pregnancy are substantial and only the childbearing individual can weigh these risks in the context of their unique physical, socioeconomic, and reproductive needs and goals. We will continue to argue that the choice should always be theirs to make. The decision to terminate or continue a pregnancy is a personal and private health care decision. We should not take lightly the task entrusted to us to confidentially discuss these topics, support our patients’ decisions, and mitigate risks as best we can. We will continue to stand up for reproductive autonomy and justice, and support access to comprehensive abortion services for all patients with kidney disease. As nephrologists, we must unite post-Roe to engage in multidisciplinary care that ensures all patients receive comprehensive, personalized, and unbiased family planning services that includes the entire spectrum of reproductive health care.
Authors’ Full Names and Academic Degrees
Andrea L. Oliverio, MD, MSc, and Monica L. Reynolds, MD, MSCR.
Dr Oliverio is supported by National Institute of Diabetes and Digestive and Kidney Diseases grant K23 DK123413.
The authors declare that they have no relevant financial interests.
Received July 5, 2022. Evaluated by 3 external peer reviewers, with direct editorial input from an Associate Editor, a Deputy Editor, and the Editor-in-Chief. Accepted in revised form August 23, 2022.
Abortion Policy in the Absence of Roe. Guttmacher Institute.