In observance of World Kidney Day and International Women’s Day 2018, Giorgina B. Piccoli, MD, of the University of Turin in Italy, and colleagues described the challenges and unanswered questions in the diagnosis and treatment of women with kidney diseases in a recent paper published in Pediatric Nephrology.

“The coinciding of World Kidney Day and International Women’s Day offers an opportunity to develop and define best practices and future research agendas, and ultimately, to optimize the outcomes of all people living with or at risk for kidney disease,” the authors wrote.

Women face unique challenges to their kidney health, according to their report. In regions of the world, women have less access to medical care than men. Along with pregnancy come increased risks of acute kidney injury (AKI), chronic kidney disease (CKD), and sequelae from flares of autoimmune disorders. Preeclampsia can lead to permanent kidney damage via AKI, tubular damage, and podocyte loss. Pregnant women with pre-existing CKD may experience placental dysfunction with increased risks for premature delivery, hypertensive disorders, and preeclampsia. The risks for adverse pregnancy outcomes increase with CKD stage, and may be higher in glomerular nephropathies, autoimmune diseases, and diabetic nephropathy.

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Specific autoimmune diseases, such as systemic lupus erythematosus (SLE), rheumatoid arthritis, and systemic scleroderma disproportionally affect women, and both these diseases and their treatments can harm kidneys.

In addition, fewer women than men start hemodialysis with an arteriovenous fistula, Dr Piccoli and her coauthors stated. Although women are more likely to donate a kidney, they are less likely to receive one from living or deceased donors.

There are myriad outstanding questions, according to the authors: Will increases in in vitro fertilization and multiple pregnancies lead to more CKD and cardiovascular disease in women? How should we define preconception risks of pregnancy with respect to current proteinuria cut offs? When should a pregnant woman start dialysis? What unique risks do female living kidney donors have? Are there sex differences in therapeutic responses to medication? The list goes on.

“Advocating for improved access to care for women is critical to maintain the health of families, communities, and populations,” Dr Piccoli and her colleagues concluded. “Focused studies on the unique contribution of sex hormones, or the interaction of sex hormones and other physiology, is important to improve our understanding of the progression of kidney diseases.”

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Piccoli GB, Alrukhaimi M, Liu ZH, Zakharova E, and Levin A. What we do and do not know about women and kidney diseases: Questions unanswered and answers unquestioned. Reflection on World Kidney Day and International Woman’s Day. Ped Nephrol. doi:10.1007/s00467-018-3917-3