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Kidneys and women's health: key challenges and considerations


The theme of World Kidney Day 2018 is 'kidneys and women's health: include, value, empower'. To mark this event, Nature Reviews Nephrology asked four leading researchers to discuss key considerations related to women's kidney health, including specific risk factors, as well as the main challenges and barriers to care for women with kidney disease and how these might be overcome. They also discuss policies and systems that could be implemented to improve the kidney health of women and their offspring and the areas of research that are needed to improve the outcomes of kidney disease in women.

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Figure 1: The male:female ratio of the incidence of end-stage renal disease across the lifespan.
Figure 2: Key factors that underlie poor kidney health and adverse outcomes in women.


  1. 1

    Eckardt, K.-U. et al. Evolving importance of kidney disease: from subspecialty to global health burden. Lancet 382, 158–169 (2013).

    PubMed  PubMed Central  Google Scholar 

  2. 2

    Mills, K. T. et al. A systematic analysis of worldwide population-based data on the global burden of chronic kidney disease in 2010. Kidney Int. 88, 950–957 (2015).

    Article  Google Scholar 

  3. 3

    Tsokos Systemic Lupus Erythematosus, G. C. N. Engl. J. Med. 365, 2110–2121 (2011).

  4. 4

    Ramjee, G. & Daniels, B. Women and HIV in sub-Saharan Africa. AIDS Res. Ther. 10, 30 (2013).

    Article  Google Scholar 

  5. 5

    Islam, F. M., Wu, J., Jansson, J. & Wilson, D. P. Relative risk of renal disease among people living with HIV: a systematic review and meta-analysis. BMC Public Health. 12, 234 (2012).

    Article  Google Scholar 

  6. 6

    Dielubanza, E. J. & Schaeffer, A. J. Urinary tract infections in women. Med. Clin. North Am. 95, 27–41 (2011).

    Article  Google Scholar 

  7. 7

    Gyamlani, G. & Geraci, S. A. Kidney disease in pregnancy:(Women's Health Series). South Med. J. 106, 519–525 (2013).

    Article  Google Scholar 

  8. 8

    Carrero, J. J., Hecking, M., Ulasi, I., Sola, L. & Thomas, B. Chronic Kidney Disease, Gender, and Access to Care: A Global Perspective. Semin. Nephrol. 37, 296–308 (2017).

    Article  Google Scholar 

  9. 9

    Xu, R. et al. Gender differences in age-related decline in glomerular filtration rates in healthy people and chronic kidney disease patients. BMC Nephrol. 11, 20 (2010).

    Article  Google Scholar 

  10. 10

    Nitsch, D. et al. Associations of estimated glomerular filtration rate and albuminuria with mortality and renal failure by sex: a meta-analysis. BMJ 346, f324 (2013).

    Article  Google Scholar 

  11. 11

    CDC Office of Women's Health. Leading Causes of Death in Females, 2014 (current listing). Centers for Disease Control and Prevention (2017).

  12. 12

    Saran, R. et al. US Renal Data System 2016 annual data report: epidemiology of kidney disease in the United States. Am. J. Kidney Dis. 69, A7–A8 (2017).

    Article  Google Scholar 

  13. 13

    Kummer, S., von Gersdorff, G., Kemper, M. J. & Oh, J. The influence of gender and sexual hormones on incidence and outcome of chronic kidney disease. Pediatr. Nephrol. 27, 1213–1219 (2012).

    Article  Google Scholar 

  14. 14

    Benjamin, E. J. et al. Heart disease and stroke statistics — 2017 update: a report from the American Heart Association. Circulation 135, e146–e603 (2017).

    Article  Google Scholar 

  15. 15

    Wild, S., Roglic, G., Green, A., Sicree, R. & King, H. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care 27, 1047–1053 (2004).

    Article  Google Scholar 

  16. 16

    Sullivan, J. C. & Gillis, E. E. Sex and gender differences in hypertensive kidney injury. Am. J. Physiol. Renal Physiol. 313, F1009–F1017 (2017).

    Article  Google Scholar 

  17. 17

    Inada, A. et al. Adjusting the 17beta-estradiol-to-androgen ratio ameliorates diabetic nephropathy. J. Am. Soc. Nephrol. 27, 3035–3050 (2016).

    CAS  Article  Google Scholar 

  18. 18

    Hodis, H. N., Collins, P., Mack, W. J. & Schierbeck, L. L. The timing hypothesis for coronary heart disease prevention with hormone therapy: past, present and future in perspective. Climacteric 15, 217–228 (2012).

    CAS  Article  Google Scholar 

  19. 19

    Afshin, A. et al. Health effects of overweight and obesity in 195 countries over 25 years. N. Engl. J. Med. 377, 13–27 (2017).

    Article  Google Scholar 

  20. 20

    Zhang, Q. L. & Rothenbacher, D. Prevalence of chronic kidney disease in population-based studies: systematic review. BMC Public Health 8, 117 (2008).

    Article  Google Scholar 

  21. 21

    Neugarten, J., Acharya, A. & Silbiger, S. R. Effect of gender on the progression of nondiabetic renal disease: a meta-analysis. J. Am. Soc. Nephrol. 11, 319–329 (2000).

    CAS  PubMed  Google Scholar 

  22. 22

    Coresh, J. et al. Chronic kidney disease awareness, prevalence, and trends among U. S. adults, 1999 to 2000. J. Am. Soc. Nephrol. 16, 180–188 (2005).

    Article  Google Scholar 

  23. 23

    Raymond, S. U., Greenberg, H. M. & Leeder, S. R. Beyond reproduction: women's health in today's developing world. Int. J. Epidemiol. 34, 1144–1148 (2005).

    Article  Google Scholar 

  24. 24

    Piccoli, G. B. et al. Risk of adverse pregnancy outcomes in women with CKD J. Am. Soc. Nephrol. 26, 2011–2022 (2015).

    Article  Google Scholar 

  25. 25

    Hoy, W. E. Kidney disease in Aboriginal Australians: a perspective from the Northern Territory. Clin. Kidney J. 7, 524–530 (2014).

    Article  Google Scholar 

  26. 26

    Carrero, J. J. et al. Sex differences in the impact of diabetes on mortality in chronic dialysis patients. Nephrol. Dial. Transplant. 26, 270–276 (2010).

    Article  Google Scholar 

  27. 27

    Vikse, B. E., Irgens, L. M., Bostad, L. & Iversen, B. M. Adverse perinatal outcome and later kidney biopsy in the mother. J. Am. Soc. Nephrol. 17, 837–845 (2006).

    Article  Google Scholar 

  28. 28

    Vikse, B. E., Irgens, L. M., Leivestad, T., Skjaerven, R. & Iversen, B. M. Preeclampsia and the risk of end-stage renal disease. N. Engl. J. Med. 359, 800–809 (2008).

    CAS  Article  Google Scholar 

  29. 29

    Kattah, A. G. et al. Preeclampsia and ESRD: the role of shared risk factors. Am. J. Kidney Dis. 69, 498–505 (2017).

    Article  Google Scholar 

  30. 30

    Mosca, L. et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women — 2011 update: a guideline from the american heart association. Circulation 123, 1243–1262 (2011).

    Article  Google Scholar 

  31. 31

    Bushnell, C. et al. Guidelines for the prevention of stroke in women: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 45, 1545–1588 (2014).

    Article  Google Scholar 

  32. 32

    Scales, C. D. Jr et al. Changing gender prevalence of stone disease. J. Urol. 177, 979–982 (2007).

    Article  Google Scholar 

  33. 33

    Levin, A. et al. Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy. Lancet 390, 1888–1917 (2017).

    Article  Google Scholar 

  34. 34

    Garg, A. X. et al. Gestational hypertension and preeclampsia in living kidney donors. N. Engl. J. Med. 372, 124–133 (2015).

    CAS  Article  Google Scholar 

  35. 35

    Sarnak, M. J. et al. Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Hypertension 42, 1050–1065 (2003).

    CAS  Article  Google Scholar 

  36. 36

    Cobo, G. et al. Sex and gender differences in chronic kidney disease: progression to end-stage renal disease and haemodialysis. Clin. Sci. 130, 1147–1163 (2016).

    Article  Google Scholar 

  37. 37

    Gordon, C. et al. The British Society for Rheumatology guideline for the management of systemic lupus erythematosus in adults. Rheumatology 1, e1–e45 (2018).

    Article  Google Scholar 

  38. 38

    Rathi, M. et al. Comparison of low-dose intravenous cyclophosphamide with oral mycophenolate mofetil in the treatment of lupus nephritis Kidney Int. 89, 235–242 (2016).

    CAS  Article  Google Scholar 

  39. 39

    Webster, P., Lightstone, L., McKay, D. B. & Josephson, M. A. Pregnancy in chronic kidney disease and kidney transplantation. Kidney Int. 91, 1047–1056 (2017).

    Article  Google Scholar 

  40. 40

    Ehrhardt, A. A., Sawires, S., McGovern, T., Peacock, D. & Weston, M. Gender, empowerment, and health: what is it? How does it work? J. Acquir. Immune Defic. Syndr. 51 (Suppl. 3), S96–S105 (2009).

    Article  Google Scholar 

  41. 41

    Schmittdiel, J. et al. Missed opportunities in cardiovascular disease prevention?: low rates of hypertension recognition for women at medicine and obstetrics-gynecology clinics. Hypertension 57, 717–722 (2011).

    CAS  Article  Google Scholar 

  42. 42

    Smyth, A., Radovic, M. & Garovic, V. D. Women, kidney disease, and pregnancy. Adv. Chron. Kidney Dis. 20, 402–410 (2013).

    Article  Google Scholar 

  43. 43

    Smith, S. M. et al. Cardiovascular and mortality risk of apparent resistant hypertension in women with suspected myocardial ischemia: a report from the NHLBI-sponsored WISE Study. J. Am. Heart Assoc. 3, e000660 (2014).

    Article  Google Scholar 

  44. 44

    Schwartz, J. B. Gender-specific implications for cardiovascular medication use in the elderly optimizing therapy for older women. Cardiol. Rev. 11, 275–298 (2003).

    Article  Google Scholar 

  45. 45

    Hecking, M. et al. Sex-specific differences in hemodialysis prevalence and practices and the male-to-female mortality rate: the Dialysis Outcomes and Practice Patterns Study (DOPPS). PLoS Med. 11, e1001750 (2014).

    Article  Google Scholar 

  46. 46

    Jindal, R. M., Ryan, J. J., Sajjad, I., Murthy, M. H. & Baines, L. S. Kidney transplantation and gender disparity. Am. J. Nephrol. 25, 474–483 (2005).

    Article  Google Scholar 

  47. 47

    Pestana, J. M. Clinical outcomes of 11,436 kidney transplants performed in a single center — Hospital do Rim. J. Bras. Nefrol. 39, 287–295 (2017).

    Article  Google Scholar 

  48. 48

    Ainsworth, M., Beegle, K. & Nyamete, A. The impact of women's schooling on fertility and contraceptive use: a study of fourteen sub-Saharan African countries. World Bank Econ. Rev. 10, 85–122 (1996).

    Article  Google Scholar 

  49. 49

    Finkelstein, F. O., Smoyer, W. E., Carter, M., Brusselmans, A. & Feehally, J. Peritoneal dialysis, acute kidney injury, and the Saving Young Lives program. Perit. Dial. Int. 34, 478–480 (2014).

    Article  Google Scholar 

  50. 50

    Kew, S. et al. Cardiometabolic implications of postpartum weight changes in the first year after delivery. Diabetes Care 37, 1998–2006 (2014).

    CAS  Article  Google Scholar 

  51. 51

    American College of Obstetricians and Gynecologists & Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet. Gynecol. 122, 1122–1131 (2013).

  52. 52

    von Dadelszen, P. et al. Fall in mean arterial pressure and fetal growth restriction in pregnancy hypertension: a meta-analysis. Lancet 355, 87–92 (2000).

    CAS  Article  Google Scholar 

  53. 53

    Magee, L. A. et al. Less-tight versus tight control of hypertension in pregnancy. N. Engl. J. Med. 372, 407–417 (2015).

    CAS  Article  Google Scholar 

  54. 54

    Baxmann, A. C. et al. Influence of muscle mass and physical activity on serum and urinary creatinine and serum cystatin C. Clin. J. Am. Soc. Nephrol. 3, 348–354 (2008).

    CAS  Article  Google Scholar 

  55. 55

    [No authors listed.] Chronic kidney disease in adults: assessment and management. Clinical guideline [CG182]. National Institute for Health and Care Excellence (2015).

  56. 56

    Bramham, K. et al. Diagnostic and predictive biomarkers for pre-eclampsia in patients with established hypertension and chronic kidney disease Kidney Int. 89, 874–885 (2016).

    CAS  Article  Google Scholar 

  57. 57

    Melloni, C. et al. Representation of women in randomized clinical trials of cardiovascular disease prevention. Circ. Cardiovasc. Qual. Outcomes 3, 135–142 (2010).

    Article  Google Scholar 

  58. 58

    Sprint Research Group et al. A randomized trial of intensive versus standard blood-pressure control. N. Engl. J. Med. 373, 2103–2116 (2015).

  59. 59

    Sandberg, K., Ji, H. & Hay, M. Sex-specific immune modulation of primary hypertension. Cell. Immunol. 294, 95–101 (2015).

    CAS  Article  Google Scholar 

  60. 60

    Barreto, F. C. et al. Osteoporosis in hemodialysis patients revisited by bone histomorphometry: a new insight into an old problem. Kidney Int. 69, 1852–1857 (2006).

    CAS  Article  Google Scholar 

  61. 61

    Houssiau, F. Why will lupus nephritis trials not fail anymore? Rheumatology 56, 677–678 (2017).

    CAS  PubMed  Google Scholar 

  62. 62

    Pregnancy and Chronic Kidney Disease Rare Disease Group. Pregnancy and Chronic Kidney Disease–RDG. RareRenal (2017).

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L.L. is grateful to have worked with and learned from thousands of women patients, as well as innumerable wise women colleagues near and far, all of whom have informed her answers.

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All authors contributed equally to the preparation of this manuscript.

Corresponding authors

Correspondence to Gloria E. Ashuntantang or Vesna D. Garovic or Ita P. Heilberg or Liz Lightstone.

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Competing interests

The authors declare no competing financial interests.

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Ashuntantang, G., Garovic, V., Heilberg, I. et al. Kidneys and women's health: key challenges and considerations. Nat Rev Nephrol 14, 203–210 (2018).

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