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Women and kidney health in emerging countries

Women and kidney health in emerging countries. Dr Manisha Sahay Professor and Head Nephrology Osmania Medical college and hospital Hyderabad. Eighth leading cause of death among women. 600,000 women die every year from C hronic Kidney disease

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Women and kidney health in emerging countries

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  1. Women and kidney health in emerging countries Dr Manisha Sahay Professor and Head Nephrology Osmania Medical college and hospital Hyderabad

  2. Eighth leading cause of death among women. 600,000 women die every year from Chronic Kidney disease Chronic kidney disease affects 195 million women worldwide

  3. Problem compounded in emerging economies

  4. Why women different?

  5. Nature protects women • Women bring life into the world • In the general population women have a longer life expectancy than men • prevalence of cardiovascular risk factors and events in women • Murray, Global Burden of disease, Lancet ,1997 • Increases risk post menopausal

  6. Kidney health in women

  7. Anatomic differences • Kidneys smaller and lighter • 300 gmvs 350 gm • Have a 15% lower GFR

  8. Physiological differences Females Estrogen Protective Testosterone less protection Different actions of hormones on transporters in the kidneys Drug effects and toxicities

  9. Testosterone Male hormone • Promotes apoptosis of proximal tubule cells - Verzola, BBRC, 2009 • Testosterone NO • Ahmed et al, CJASN,2007 • Carrero, Curr opinion in H, 2010 • Estrogens have • anti-fibrotic • anti-apoptotic effects • NO syntheis • anti inflammatory • Inhibits RAS • Stringer, KI, 2005 • Elliot KI 2007 Nature protects Females • Interaction of hormones with specific kidney receptors • -Sandberg, Gend Medicine, 2008

  10. What about Renal diseases

  11. Proteinuria less in females • Estrogen reduces proteinuria • Oral contraceptive use associated with macroalbuminuria • Ahmed Diabetes care, 2005 • Type-2 diabetic proteinuric hypertensive women who received HRT had proteinuria & creatinine clearance • Agarwal, M, AJKD,2005

  12. Chronic kidney disease less in females • CKD Males: females 70:30 • (hospital based registry) • Rajapurkar, BMC, 2012 • CKD Bangladesh M:F 1.2:1 • Mahmud Hasan, CBMJ, 2012 • CKD Pakistan 1:1 • Ullah, SJKDT, 2015

  13. Glomerular disease- biopsy 10 year data Osmania Men 1717 Women 1279

  14. CKD progression slightly less in women • Men were associated with a worse CKD progression • Evans, AJKD, 2005, Eriksen, KI, 2006 • In 840 non-diabetics, loss of renal function slower in women esp if younger and premenopausal • Coggins, NDT,1998 • NeugartenJ,. JASN, 2000;Eriksen, KI, 2006 • Seliger. Gender & renal disease. CurrOpinNephrolHypertens 2001 • ADPKD, IgA, MN, and ‘CKDu’ progress at a slower rate than it does in BP- and lipid levels-matched men • Neugarten et al, JASN, 2000 • No difference males and females –post menopausal • Jafar, NDT, 2000

  15. Iseki K, Iseki C,KI 1996

  16. Thus most incidence and prevalance of diseases seems to be less in women and progression to CKD slower in females

  17. Then why we are talking about kidney health of women??

  18. What makes a woman different from man??Men are from MarsWomen are from Venus!!

  19. Pregnancy is the essence of womanhood

  20. Pregnancy • Women face additional risks to their kidney health, specifically during pregnancy • Global Burden of Diseases website. Data on Chronic Kidney Disease prevalence and mortality in women. Available from: https://vizhub.healthdata.org/gbd-compare/ • Pregnancy is a major stressor • Normal pregnancy does not harm the mother • Pregnancy if complicated or pregnancy in CKD women detrimental

  21. Pregnancy AKI in emerging countries 30 times more common in merging countries Swati Rao, KI reports, 2016

  22. Renal failure In pregnancy Developed/emerging countries PET Poor Septic abortion Sepsis Bangladesh, 2012 • Early pregnancy AKI • Septic abortion • Later pregnancy AKI • Preeclampsia (PE)/HT • 3% women • Piccoli , J Nephrology, 2011 • Ante partum hemorrhage • Post partum hemorrhage • Puerperal sepsis • Acute fatty liver of pregnancy • HUS

  23. PET (High BP in pregnancy) Most important cause of renal failure • PET is the commonest glomerular disease in the world • 3-10% of all pregnancies • Liz Livingstone, KI reports, 2018

  24. placental dysfunction damages kidneys CKD cause placental dysfunction Impaired Angiogenesis,Vassoconstritcion, oxidant stress, inflammation

  25. PET • Maternal deaths • 76,000 maternal deaths worldwide / year • 16% of maternal deaths in LMICs • Endecclapsia.org • 3-4X risk of stroke & heart disease • Munkhaugen, NDT,2009 • Agatha, J Nephr, 2017 • Kidney failure • 4 to 5 times more likely to develop kidney failure

  26. PET causes CKD in women • PE is a risk factor for the future development of CKD and ESRD in the mother. • Mol, Lancet, 2016 • podocyteloss is a hallmark of PE, suggesting permanent glomerular damage • Garovic, CJASN,2014 • Endotheliosismay herald glomerulosclerosis • tubular and vascular damage may coexist • Shiki, AJN,1990 • Cortical necrosis dreaded outcome

  27. Healthy pregnant female becomes dialysis dependent CKD 105 cases over 7 years 39% obstetric causes of cortical necrosis

  28. PET does not spare the child • Babies born to mothers with preeclampsia may • May not be born at all (Intrauterine death) • preterm • low birth weight/small for gestational age • Have increased risk of kidney disease • low nephron number , increased risk of CKD, high BP later in life • Fizpatrick, Int Journal of women’s health, 2016

  29. 4 important diseases in women

  30. SLE

  31. Systemic lupus erythematosus • Affects women (9:1 F:M) in reproductive yrs. • Immunomodulatory effects of estrogen make SLE common in females • SLE affects kidneys in 50% • ESKD-10% • major risk factor for morbidity and mortality • Poor Pregnancy outcomes • PET 7.6% • APLA worsens prognosis • Fetal heart blocks if SSA/SSB • Treatment is also toxic - infertility

  32. DKD in women • DKD prevalence more in men • Luk, Diabetes care 2008, Ohta, Diabetes med 2010] • DKD risk factors more in women ie obesity and hypertension • Older Women with diabetes have an increased prevalence of advanced DKD • Margaret, AJN, 2012 (Pathways study) • McFarlane, Jr Clinical hypetension, 2005

  33. Obesity and kidney disease • 24.9% of CKD in women is associated with overweight and obesity vs 13.8% in men • Wang, KI, 2008 • prevalence of obesity • 49%, 57%in females • abdominal obesity • 63% women • 48% men • ICKD, GI, 2017

  34. Urinary tract infections Frequent in women Recurrent UTI common Pregnancy UTI may become complicated Important to rule out underlying cause esp in girls Treatment of pregnancy UTI important

  35. So we have understood… Kidney disease generally less Pregnancy UTI SLE DM Obesity

  36. What about treatment for renal disease?Dialysistransplantation

  37. Dialysis in men and women

  38. Less Women on dialysisacross all economies.. • Our study from India 73% patients on dialysis are men • Maaz Sheikh, VJ, Manisha Sahay et al. KI 2018 • Nationwide survey of ESRD by Japanese Society for Dialysis therapy revealed a higher incidence and prevalence in men • KunitoshiAsaki, KI, 2008 • Studies in Africa show that men were more likely to receive RRT than women • Halle, BMC, 2015 • US study reports women having a significantly higher odds ratio of 1.70 for late initiation of dialysis compared to men • Kausz, JASN 2000

  39. Why less dialysis in females? ?? ESRD less common in females Less females seek medical attention Less females receive medical attention

  40. CENTRE OSMANIA HOSPITAL3000 dialysis per month1008 forfemales

  41. Peritoneal dialysis in females • ed risk of encapsulating peritoneal sclerosis (EPS) in women undergoing peritoneal dialysis • EPS have shown improvement with tamoxifentherapy, an antiestrogen compound . • Weisinger JR Kidney Int 2000 •  Hernandez EKidneyInt 2003

  42. Transplantation in men and women

  43. Universal truth..All emerging countries.. Women donate Men receive

  44. All across the world …. • US, France, China, India, Pakistan, Srilanka • ( Transplant rates lower in women than men) • Less women registered on national transplant waiting lists • Mothers are more likely to be donors, as are female spouses • Couchod, Tx 2012 • Liu, ClinTx 2013 • Saran AJKD 2017

  45. Osmania data 700 live related transplants 85% donors females 87% recipients males Mothers, sisters, spouses

  46. Even girl child at disadvantage… Survey from 35 countries participating in European Society for Pediatric Nephrology/European Renal Association- European Dialysis and Transplant Association Registry reported that girls had a lower access to renal transplantation than boys • Hogan AJT 2016

  47. Is female kidney better?

  48. Are female kidneys better? • Lower number of nephrons • express more HLA antigens and are more antigenic • Zeier M,. J Am SocNephrol. 2002 • more susceptible to nephrotoxic effects of immunosuppressants • Shibue T, Clin Transplant. 1987 • Female donor kidneys have a worse 5-year survival • Głyda M, Pol PrzeglChir. 2011 • Shibue T, ClinTransplant. 1987

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