Contraception and Kidney Disease

Chronic kidney disease reduces fertility but does not remove it, and pregnancy in advanced disease carries high maternal and foetal risk. Many medicines used in kidney disease and after transplant are teratogenic (ACE inhibitors, angiotensin receptor blockers, mycophenolate, cyclophosphamide). Contraception must therefore be reliable and safe for the kidney, blood pressure and clotting.

Assessment. Stage of kidney disease (eGFR), proteinuria or nephrotic syndrome, dialysis modality, hypertension, bone mineral disorder, anaemia, thrombosis risk, medicines, and pregnancy intention. Check for lupus nephritis and diabetes nephropathy.

Nephrotic syndrome. High thrombosis risk because of urinary loss of antithrombin and other factors; oestrogen is avoided.

Dialysis. Fertility is low but pregnancy can occur; contraception is advised.

Effectiveness. Method failure is as expected for the method; absorption of oral methods is not meaningfully changed.

Eligibility.

Method comparison. The levonorgestrel 52 mg device and implants are preferred; the copper device can increase bleeding in anaemia and uraemic platelet dysfunction. DMPA is avoided in nephrotic syndrome, dialysis and advanced bone disease because of thrombotic risk and bone loss.

Medicines. Hormonal contraceptives do not harm kidney function and are not nephrotoxic. Mycophenolate may lower contraceptive hormone exposure, so two methods are advised.

Special groups. Patients after transplant follow the transplant article. Adolescents with kidney disease have delayed puberty and need early counselling.

Regimen lines.

• Levonorgestrel 52 mg device: 5 years; copper T 380A: up to 12 years; insertion within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; backup 7 days if inserted after day 7 of bleeding.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; drospirenone raises potassium, so avoid it when eGFR is under 30 or potassium is high; backup 2 days after a late or missed pill.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, only in stage 1 to 3 disease without nephrotic syndrome or hypertension.

• Combined methods: not used in most patients with CKD and hypertension, nephrotic syndrome or dialysis.

Bleeding and anaemia. Heavy bleeding is common; treat with the levonorgestrel device, iron and erythropoiesis-stimulating therapy as indicated.

Preconception. Pregnancy is planned with nephrology review; stop teratogens and optimise blood pressure and eGFR first.

Follow up. Review blood pressure, haemoglobin, bleeding and medicines at each nephrology visit.

Bleeding treatment. Avoid NSAIDs in CKD. Tranexamic acid is dose-reduced in proportion to creatinine and avoided in advanced renal impairment without specialist advice.

Thrombosis. Nephrotic syndrome and dialysis increase risk; treat leg swelling or chest pain urgently and stop any oestrogen-containing method.

Hyperkalaemia. Drospirenone-containing pills can raise potassium in advanced disease and with ACE inhibitors, angiotensin receptor blockers or potassium-sparing diuretics; check potassium after starting.

Red flags. Rapid rise in creatinine, severe hypertension, chest pain, leg swelling, heavy bleeding.

Referral and escalation. Refer pregnancy, progressive kidney disease, severe hypertension and thromboembolism to nephrology and obstetrics.