Fertility and reproductive care in chronic kidney disease

Pre-gestational counselling for women living with CKD: starting from the bright side

Pregnancy in women living with chronic kidney disease (CKD) was often discouraged due to the risk of adverse maternal-fetal outcomes and the progression of kidney disease. This negative attitude has changed in recent years, with greater emphasis on patient empowerment than on the imperative 'non nocere'. Although risks persist, pregnancy outcomes even in advanced CKD have significantly improved, for both the mother and the newborn. Adequate counselling can help to minimize risks and support a more conscious and informed approach to those risks that are unavoidable. Pre-conception counselling enables a woman to plan the most appropriate moment for her to try to become pregnant. Counselling is context sensitive and needs to be discussed also within an ethical framework. Classically, counselling is more focused on risks than on the probability of a successful outcome. 'Positive counselling', highlighting also the chances of a favourable outcome, can help to strengthen the patient-physician relationship, which is a powerful means of optimizing adherence and compliance. Since, due to the heterogeneity of CKD, giving exact figures in single cases is difficult and may even be impossible, a scenario-based approach may help understanding and facing favourable outcomes and adverse events. Pregnancy outcomes modulate the future life of the mother and of her baby; hence the concept of 'post partum' counselling is also introduced, discussing how pregnancy results may modulate the long-term prognosis of the mother and the child and the future pregnancies.

Parental recovered acute kidney injury causes prenatal renal dysfunction and fetal growth restriction with sexually dimorphic implications for adult offspring

Introduction: Acute kidney injury (AKI) is rapidly increasing in global incidence and a healthcare burden. Prior maternal AKI diagnosis correlates with later pregnancy complications. As pregnancy influences developmental programming, we hypothesized that recovered parental AKI results in poor pregnancy outcomes, impaired fetal growth, and adult offspring disease. Methods: Using a well-characterized model of rhabdomyolysis-induced acute kidney injury (RIAKI), a form of AKI commonly observed in young people, we confirmed functional renal recovery by assessing glomerular filtration rate (GFR) 2 weeks following RIAKI. We bred sham and recovered RIAKI sires and dams in timed, matched matings for gestational day (GD) 16.5 and offspring (birth-12 weeks, 6 months) study. Results: Despite a normal GFR pre-pregnancy, recovered RIAKI dams at GD16.5 had impaired renal function, resulting in reduced fetoplacental ratios and offspring survival. Pregnant RIAKI dams also had albuminuria and less renal megalin in the proximal tubule brush border than shams, with renal subcapsular fibrosis and higher diastolic blood pressure. Growth-restricted offspring had a reduced GFR as older adults, with evidence of metabolic inefficiency in male offspring; this correlated with reduced renal AngII levels in female offspring from recovered RIAKI pairings. However, the blood pressures of 6-month-old offspring were unaffected by parental RIAKI. Conclusions: Our mouse model demonstrated a causal relationship among RIAKI, gestational risk, and developmental programming of the adult-onset offspring GFR and metabolic dysregulation despite parental recovery.

Fertility Challenges: The Complexities of Retrograde Ejaculation and Cornual Block in Reproductive Health

Infertility, a complicated reproductive health issue that affects both men and women, can have a variety of causes, from anatomical abnormalities to hormone imbalances. This research addresses a couple who have been struggling with infertility for the past four years: a 31-year-old woman with bilateral tubal blockage and her 34-year-old spouse who suffered from primary infertility due to retrograde ejaculation (RE) for the same period. Analyzing the male's semen sample, it was discovered that there were dead sperm and urine, indicating RE. A hysterosalpingography indicated bilateral tubal obstruction in the female partner. Pelvic factors were examined via laparoscopy, which played a crucial role in addressing further issues. The procedure of treatment included testicular sperm aspiration for sperm extraction and intracytoplasmic sperm injection. Hormonal support was involved in the follow-up, and on the 14th day, the β-hCG test came back positive. The intricate procedures of RE and cornual block are discussed, with a focus on how they affect reproductive health.

Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanic/Latino individuals are less likely to receive optimal treatment for chronic kidney disease than non-Hispanic whites. This may be particularly detrimental for women of reproductive age as chronic kidney disease increases risk for infertility, menstrual irregularities, and pregnancy loss. While these maternal outcomes have been associated with advanced chronic kidney disease, their occurrence in early chronic kidney disease is unclear.

OBJECTIVES/DESIGN

Using baseline (2008-2011) and second study visit (2014-2017) data from the Hispanic Community Health Study/Study of Latinos, we retrospectively assessed the prevalence of chronic kidney disease as well as the association between chronic kidney disease and self-reported infertility, cessation of menses, hysterectomy, and nonviable pregnancy loss (experienced at less than 24 weeks gestation) in women of reproductive age (18-45 years).

METHODS

Multivariable survey logistic regression analyses determined the unadjusted and multivariable-adjusted prevalence odds ratios with 95% confidence intervals between chronic kidney disease and the separate outcomes.

RESULTS

Among 2589 Hispanic/Latino women included (mean age = 31.4 years), 4.6% were considered to have chronic kidney disease. In adjusted analyses, women with chronic kidney disease did not have a significantly increased odds of infertility (odds ratio = 1.02, 95% confidence interval = 0.42-2.49), cessation of menses (odds ratio = 1.25, 95% confidence interval = 0.52-3.04), or hysterectomy (odds ratio = 1.17, 95% confidence interval = 0.61-2.25) compared to those without chronic kidney disease. In those with chronic kidney disease, the adjusted odds of a nonviable pregnancy loss occurring after baseline visit were increased (odds ratio = 2.11, 95% confidence interval = 0.63-7.02) but not statistically significance.

CONCLUSION

The presence of early stage chronic kidney disease did not confer a significant risk of infertility, cessation of menses, or nonviable pregnancy loss.

Integrated metabolomics and proteomics reveal biomarkers associated with hemodialysis in end-stage kidney disease

Background: We hypothesize that the poor survival outcomes of end-stage kidney disease (ESKD) patients undergoing hemodialysis are associated with a low filtering efficiency and selectivity. The current gold standard criteria using single or several markers show an inability to predict or disclose the treatment effect and disease progression accurately. Methods: We performed an integrated mass spectrometry-based metabolomic and proteomic workflow capable of detecting and quantifying circulating small molecules and proteins in the serum of ESKD patients. Markers linked to cardiovascular disease (CVD) were validated on human induced pluripotent stem cell (iPSC)-derived cardiomyocytes. Results: We identified dozens of elevated molecules in the serum of patients compared with healthy controls. Surprisingly, many metabolites, including lipids, remained at an elevated blood concentration despite dialysis. These molecules and their associated physical interaction networks are correlated with clinical complications in chronic kidney disease. This study confirmed two uremic toxins associated with CVD, a major risk for patients with ESKD. Conclusion: The retained molecules and metabolite-protein interaction network address a knowledge gap of candidate uremic toxins associated with clinical complications in patients undergoing dialysis, providing mechanistic insights and potential drug discovery strategies for ESKD.

Female Infertility in Chronic Kidney Disease

This review summarises the current literature regarding infertility in women with chronic kidney disease (CKD), describing the epidemiology, pathophysiology, investigations, and management options. The pathophysiology is multifactorial, with proposed mechanisms including disruption of the hypothalamus-pituitary-ovarian axis, chronic inflammation, oxidative stress, psychological factors, and gonadotoxic effects of medications such as cyclophosphamide. Diagnostic investigations in CKD patients seeking to conceive should be considered earlier than in the healthy population. Investigations should include hormonal profiling, including markers such as Anti-Mullerian Hormone and imaging such as ultrasound, to evaluate ovarian reserve and identify gynaecology pathology. Treatment options for infertility in CKD patients include GnRH agonists to preserve ovarian function during cyclophosphamide treatment, as well as assisted reproductive technologies including in vitro fertilisation and ovulation induction. However, these treatments must be tailored to the individual's health status, comorbidities, fertility requirements, and CKD stage. In conclusion, fertility is an important consideration for women with CKD, necessitating early investigation and tailored management. Early discussions regarding fertility are important in order to understand patients' family planning and allow for prompt referral to fertility services. While challenges exist, ongoing research aims to clarify the underlying mechanism and optimise treatment strategies, which are crucial for improving quality of life and overall health outcomes.

Female Reproductive Health and Contraception Use in CKD: An International Mixed-Methods Study

Rationale & Objective

Female reproductive health is recognized as a predictor of morbidity, mortality, and quality of life, although data in the setting of chronic kidney disease (CKD) are limited.

Study Design

A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey. Phase 2 was semistructured interviews offered to all respondents upon survey completion.

Setting & Participants

The survey was disseminated internationally from October 4, 2021, to January 7, 2022, to individuals aged 18-50 years with both a uterus and CKD diagnosis.

Outcomes

Menstrual health and contraceptive use by CKD stage (dialysis, nondialysis CKD, and transplant).

Analytical Approach

Survey data were analyzed using descriptive statistics. Interview data were analyzed using the framework method of analysis.

Results

Of 152 respondents, 98 (mean age 33 ± 0.7 years; n = 20 dialysis, n = 59 nondialysis CKD, n = 19 transplant) satisfied the inclusion criteria, representing 3 continents. The most common causes of CKD among survey respondents were hereditary causes in dialysis (n = 6, 30%) and glomerulonephritis in nondialysis CKD (n = 22, 37%) and transplant (n = 6, 32%). The majority reported heavy menstrual bleeding (n = 12, 86% dialysis; n = 46, 94% nondialysis CKD; n = 14, 100% transplant). Less than half of participants were consistently able to afford period products. Condoms were the most common contraceptive reported. Most participants reported no contraceptive use (n = 10, 50% dialysis; n = 37, 63% nondialysis CKD; n = 7, 37% transplant), primarily because of "fear". Interviews (n = 6) revealed a perception of a relationship between kidney function and menstrual health, concerns about contraceptive use, and a desire for greater multidisciplinary care to improve kidney and reproductive health.

Limitations

Self-reported outcomes, need for internet access and a device.

Conclusions

Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Plain-Language Summary

Chronic kidney disease (CKD) in female individuals is accompanied by menstrual disorders and low contraceptive use. However, most data are limited to the dialysis and transplant populations. Therefore, this mixed-methods study aimed to describe self-assessed menstruation and contraceptive use across all stages of CKD. People aged 18-50 years with a uterus and CKD diagnosis were invited to participate in an online survey shared internationally as well as an optional telephone interview. Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Hormonal intrauterine device in women with renal transplantation: a prospective observational study

OBJECTIVE

The main objective of this study is to evaluate the rate of continuity and satisfaction with hormonal intrauterine device in renal transplant recipients.

METHODS

This was a prospective observational study. The sample consisted of patients treated at a Family Planning Outpatient Clinic, from August 2016 to September 2021. Information on each patient's age, parity, and associated diseases as well as satisfaction with the method were analyzed. Patients were invited to participate through electronic messages, and the questionnaire included questions about acceptance of the contraceptive method.

RESULTS

A total of 40 patients were included in the study. The mean age of the renal transplant patients was 32.5 years. The mean duration of hormonal intrauterine device use was 37 months. Acceptance of the method was high, with 97.5% of patients remaining on the method for 1 year and 85% of patients using the hormonal intrauterine device at the time of the study. There were no pregnancies or renal transplant complications in the study. Regarding satisfaction with the method, the majority (77.5%) scored 10.

CONCLUSION

Patients were satisfied or very satisfied with the hormonal intrauterine device. Therefore, the continuation rate was high. Furthermore, this contraceptive method proved to be safe and effective in kidney transplant recipients. No complications, graft rejection, or graft failure were observed after intrauterine hormonal device insertion and during follow-up.

Chronic kidney disease, female infertility, and medically assisted reproduction: a best practice position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology

Fertility is known to be impaired more frequently in patients with chronic kidney disease than in the general population. A significant proportion of chronic kidney disease patients may therefore need Medically Assisted Reproduction. The paucity of information about medically assisted reproduction for chronic kidney disease patients complicates counselling for both nephrologists and gynaecologists, specifically for patients with advanced chronic kidney disease and those on dialysis or with a transplanted kidney. It is in this context that the Project Group on Kidney and Pregnancy of the Italian Society of Nephrology has drawn up these best practice guidelines, merging a literature review, nephrology expertise and the experience of obstetricians and gynaecologists involved in medically assisted reproduction. Although all medically assisted reproduction techniques can be used for chronic kidney disease patients, caution is warranted. Inducing a twin pregnancy should be avoided; the risk of bleeding, thrombosis and infection should be considered, especially in some categories of patients. In most cases, controlled ovarian stimulation is needed to obtain an adequate number of oocytes for medically assisted reproduction. Women with chronic kidney disease are at high risk of kidney damage in case of severe ovarian hyperstimulation syndrome, and great caution should be exercised so that it is avoided. The higher risks associated with the hypertensive disorders of pregnancy, and the consequent risk of chronic kidney disease progression, should likewise be considered if egg donation is chosen. Oocyte cryopreservation should be considered for patients with autoimmune diseases who need cytotoxic treatment. In summary, medically assisted reproduction is an option for chronic kidney disease patients, but the study group strongly advises extensive personalised counselling with a multidisciplinary healthcare team and close monitoring during the chosen medically assisted reproduction procedure and throughout the subsequent pregnancy.

Infertility, pregnancy and breastfeeding in kidney transplantation recipients: Key issues

Chronic kidney disease (CKD), especially in advanced stages, is an important cause of infertility. In CKD patients, infertility has been linked to multiple factors. The pathophysiology of infertility related to CKD is complex and forked. Correction of modifiable factors can improve fertility in both genders. In males as well as females, successful kidney transplantation offers good chances of restoration of reproductive function. In female renal allograft recipients, recovery of reproductive functions in the post-transplant period will manifest as restoration of normal menses and ovulation. Owing to this improvement, there is a significant risk of unplanned pregnancy, hence the need to discuss methods of contraception before transplantation. In kidney transplant recipients, different contraceptive options for pregnancy planning, have been used. The selection of one contraception over another is based on preference and tolerability. Pregnancy, in renal transplanted females, is associated with physiologic changes that occur in pregnant women with native kidneys. Immunosuppressive medications during pregnancy, in a recipient with a single functioning kidney, expose the mother and fetus to unwanted complications. Some immunosuppressive drugs are contraindicated during pregnancy. Immunosuppressive medications should be discussed with renal transplant recipients who are planning to breastfeed their babies. In addition to antirejection drugs, other medications should be managed accordingly, whenever pregnancy is planned.

Menstrual Abnormalities and Reproductive Lifespan in Females with CKD: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Menstrual abnormalities and shortened reproductive lifespan are associated with shorter life expectancy and higher cardiovascular and osteoporosis risk in the general population, although the magnitude of these reproductive factor irregularities in females with CKD is unclear. This systematic review and meta-analysis aimed to summarize the current knowledge regarding menstrual abnormalities and reproductive lifespan among females with CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A comprehensive bibliographic search (MEDLINE, Embase, and Cumulative Index to Nursing and Allied Health Literature [CINAHL]) was completed from database inception to February 2022 to identify all original articles reporting on females of reproductive age with nondialysis-dependent/nonkidney transplant CKD, dialysis-dependent CKD, or kidney transplantation and menstruation patterns, age of menarche, and/or menopause. Data extraction and study quality assessment were completed in duplicate. Random effects meta-analyses were used to derive pooled proportions estimates.

RESULTS

Forty-six studies were identified, and 35 were meta-analyzed, stratified by KRT modality and reported outcome. Menstrual abnormalities were present in 19%-47% of patients on hemodialysis and 75% of patients on peritoneal dialysis. Kidney transplantation was associated with a 7%-30% decrease in menstrual abnormalities. Reproductive lifespan was 32 years (95% confidence interval, 30 to 34 years). Although significant heterogeneity was present, study quality ranged from fair to good, and no evidence of publication bias was noted.

CONCLUSIONS

Menstrual abnormalities and shorter reproductive lifespan are common in females with CKD, although kidney transplantation may improve menstrual health.

IVF pregnancy after kidney transplantation: clinical case and literature review

Kidney transplantation (KT), the optimal treatment for stage 5 chronic kidney disease (CKD), restores impaired fertility in most women of reproductive age. However, infertility occurs in some patients after successful KT. We present our own experience of overcoming secondary tubal infertility by in vitro fertilization (IVF). The patient was a 36-year-old with a transplanted kidney, who had lost two pregnancies in the past due to severe preeclampsia (PE). After the second attempt on cryo-thawed embryo transfer against the background of hormone replacement therapy, one embryo was transferred into the uterus, resulting in pregnancy. Gestational diabetes mellitus (GDM) was diagnosed in the first trimester, and a diet was prescribed. Immunosuppression with tacrolimus, azathioprine and methylprednisolone, prophylaxis of PE with low molecular weight heparin and antiplatelet drugs were administered during pregnancy. Elective cesarean section was performed at 37–38 weeks and a healthy boy was born, weighing 2760 g (25th percentile), 48 cm tall (36th percentile). A stay in the neonatal intensive care unit was not required. The baby is growing and developing normally, the mother’s renal graft function is satisfactory. So, IVF can be successfully used in post-KT patients with infertility issues, provided that the IVF program is carefully controlled, and the pregnancy is managed in a multidisciplinary manner.

Reproductive Health in Chronic Kidney Disease: The Implications of Sex and Gender

Chronic kidney disease (CKD) is frequently accompanied by reproductive health challenges in females and males alike. Progression of CKD is associated with escalating impairment of the hypothalamic-pituitary-gonadal axis, which facilitates evolving ovarian, testicular, and sexual dysfunction. Common clinical reproductive health complications in CKD include abnormal menstruation, impaired sexual health, and reduced fertility. Though sex-specific factors, such as sex hormones and gonadal function, have a strong influence on reproductive health outcomes in CKD, a person's gender and gendered experience also have important implications. Institutionalized gender, gendered perceptions of health, and health care-seeking behaviors, as well as adherence to medical care, all have critical effects on reproductive health in CKD. This review endeavors to explore the implications of both sex and gender on overall reproductive health in individuals living with CKD.

Anti-Müllerian hormone and vascular dysfunction in women with chronic kidney disease

Young women with chronic kidney disease (CKD) have disproportionately increased risk of cardiovascular mortality. Reduced anti-Müllerian hormone (AMH) is linked to poor cardiovascular outcomes in the general population, but whether AMH is associated with increased cardiovascular risk in the high-risk CKD population is unknown. This study examined the association between AMH and vascular function, validated markers of cardiovascular risk, in women with CKD. An exploratory cross-sectional study was performed in 47 young women with CKD. Laboratory measurements of AMH were collected. Using standardized protocols, endothelial function was measured with brachial artery flow-mediated dilation and hyperemic velocity time integral. Arterial stiffness was measured with aortic augmentation index and pulse wave velocity. Multivariate linear regression analyses were utilized to evaluate the association between AMH levels and each measure of vascular health. Forty women (36 ± 7 years) with non-dialysis-dependent CKD and 7 women (38 ± 6 years) with dialysis-dependent CKD participated. AMH levels were inversely associated with age (p = 0.01) but not associated with eGFR (p = 0.59) or dialysis status (p = 0.97). AMH was associated with brachial artery flow-mediated dilation (R2  = 0.21 [p = 0.03]) and aortic augmentation index (R2  = 0.20 [p = 0.04]) in the non-dialysis-dependent participants, and with aortic augmentation index in all participants (R2  = 0.18 [p = 0.03]). No association between AMH and any measure of vascular function was demonstrated in the dialysis-dependent participants. AMH levels are associated with impaired vascular function in young women with CKD and may be an important marker of future cardiovascular risk. Further investigation into this female-specific cardiovascular risk factor is warranted in this high-risk population.

Human and animal fertility studies in cystinosis reveal signs of obstructive azoospermia, an altered blood-testis barrier and a subtherapeutic effect of cysteamine in testis

Cystinosis is an inherited metabolic disorder caused by autosomal recessive mutations in the CTNS gene leading to lysosomal cystine accumulation. The disease primarily affects the kidneys followed by extra-renal organ involvement later in life. Azoospermia is one of the unclarified complications which are not improved by cysteamine, which is the only available disease-modifying treatment. We aimed at unraveling the origin of azoospermia in cysteamine-treated cystinosis by confirming or excluding an obstructive factor, and investigating the effect of cysteamine on fertility in the Ctns^-/- mouse model compared with wild type. Azoospermia was present in the vast majority of infantile type cystinosis patients. While spermatogenesis was intact, an enlarged caput epididymis and reduced levels of seminal markers for obstruction neutral α-glucosidase (NAG) and extracellular matrix protein 1 (ECM1) pointed towards an epididymal obstruction. Histopathological examination in human and mouse testis revealed a disturbed blood-testis barrier characterized by an altered zonula occludens-1 (ZO-1) protein expression. Animal studies ruled out a negative effect of cysteamine on fertility, but showed that cystine accumulation in the testis is irresponsive to regular cysteamine treatment. We conclude that the azoospermia in infantile cystinosis is due to an obstruction related to epididymal dysfunction, irrespective of the severity of an evolving primary hypogonadism. Regular cysteamine treatment does not affect fertility but has subtherapeutic effects on cystine accumulation in testis.

Does Coenzyme Q10 Supplementation Improve Testicular Function and Spermatogenesis in Male Mice with Chronic Kidney Disease?

Simple Summary

Chronic kidney disease (CKD) is found to be linked to elevated apoptosis, oxidative stress and inflammation. Moreover, lower testosterone, poorer sperm quality and lower reproductive function have also been observed. Coenzyme Q10 (CoQ10), a widely used antioxidant involved in mitochondrial energy production, is indispensable for maintaining the efficient energy system of spermatozoa and protecting their membranes from lipid peroxidation, yet there are few studies focusing on the effects of CoQ10 on CKD-induced male infertility. This study suggests that CoQ10 increases testosterone levels and improves spermatogenesis in CKD mice.

Abstract

The aim of the study was to examine the potential effects of coenzyme Q10 (CoQ10) on reproductive function in a chronic kidney disease (CKD) mouse model. Nine-week-old mice were randomly assigned to two groups: sham surgery (n = 18) and CKD surgery (n = 18). After surgery, the study groups received CoQ10 (10 mg/kg body weight dissolved in corn oil by oral gavage) or corn oil as a vehicle daily for 8 weeks. The groups that underwent 5/6 nephrectomy developed significant elevations of serum BUN and creatinine levels. The CoQ10 treatment significantly increased the serum and testicular CoQ10 levels and alleviated the poor semen quality from incomplete spermatogenesis. The testosterone concentration, in addition to the protein expression of enzymes related to testosterone biosynthesis, was also elevated, and the CKD-induced decrease in antioxidant activity in the testes was significantly ameliorated. The results suggest that CoQ10 could act against CKD-induced testicular dysfunction through improvements in the sperm function, testicular morphology, testosterone levels and related biosynthesis pathways, in addition to antioxidant activity.

α1-Acid glycoprotein and seminal parameter in chronic hemodialysis patients

INTRODUCTION

To find out the changes in seminal quality of hemodialysis chronic renal patients, we investigated the possible relationship between seminal parameter and seminal α1-acid glycoprotein levels in chronic hemodialysis patients.

METHODS

Prospective study of prevalence realized in the Hemodialysis Sector of the University Hospital of the University of Brasília, between July 2016 and December 2016. Men aged 18-60 years grouped into case groups (n = 81) represented by chronic hemodialysis patients and control group (n = 20) of healthy men without clinical or laboratory signs of infection and eugonadic. We performed a spermogram, hormonal profile, and assessment of leukocytes and seminal α1-acid glycoprotein level in the semen. The most appropriate statistical test was applied to verify differences and correlations between the studied variables.

RESULTS

The age in case and control is similar (49.47 ± 5.55 years vs 50.53 ± 4.24 years; p = 0.060). Mean level of α1-acid glycoprotein in human seminal plasma were not significantly different between case and control (48.52 ± 4.90 mg/L vs 46.33 ± 4.29 mg/L; p = 0.10) and between normosperm and oligosperm (47.76 ± 5.15 mg/L vs 49.48 ± 4.49 mg/L; p = 0.19). Mean level of α1-acid glycoprotein in human seminal plasma in the case group, which were classified into severe, moderate, mild, and normosperm, were similar to each other (p = 0.27) and did not correlate (p > 0.05) with the analyzed seminal parameters. All participants presented normal hormonal profile.

CONCLUSION

Results of this study suggest that the seminal α1-acid glycoprotein levels do not help in the initial evaluation of patients with seminal parameter changes.

You-Gui-Yin improved the reproductive dysfunction of male rats with chronic kidney disease via regulating the HIF1α-STAT5 pathway

ETHNOPHARMACOLOGICAL RELEVANCE

You-Gui-Yin (YGY) is a famous Chinese traditional medicine compound that has been used to treat renal function diseases for more than 300 years. It is recorded in Jing Yue Quanshu, which was written by a famous medical scientist named Jiebing Zhang in the Ming Dynasty.

AIM OF THE STUDY

Reproductive dysfunction is one of the most serious complications of chronic kidney disease (CKD). The aim of this study was to observe the effect of You-Gui-Yin (YGY) on reproductive dysfunction of male rats with adenine-induced CKD and to determine if any effects occurred via regulation of the HIF1α-STAT5 pathway.

MATERIALS AND METHODS

UPLC-Q-TOF-MS was used to detect the main medicinal components and conduct quality control of YGY. A total of 60 rats were randomly divided into 2 groups: the NC group (10 rats) and the CKD model group (50 rats). The CKD model rats was established by administration of adenine 150 mg kg^-1 orally for 14 days. After that, the CKD rats were randomly divided into 5 groups: the CKD group, YGY (10 g kg^-1 group, 20 g kg^-1 group, 40 g kg^-1 group) and the GUI-LU-ER-XIAN-JIAO (GL) 10 g kg^-1 group with 10 rats in each group. From the 15th day to the 45th day rats were given 150 mg kg^-1 adenine orally every other day to maintain the model (except in the NC group). The YGY groups and the GL group were orally administered the relevant drug once per day for 30 days. The NC group and the CKD group were orally administered an equal volume of normal saline for 30 days. On the 45th day, the rats' sexual behavior index was tested. On the 46th day, the rats were sacrificed. Biochemical indexes, histopathological changes of the kidneys and testes, sperm morphology, sperm abnormality rate, and key proteins in the HIF1α-STAT5 pathway in the kidney and testis were detected.

RESULTS

Thirteen components in the YGY extract were identified by UPLC-Q-TOF-MS for quality control of the YGY extract. The results of the biochemical and physiological tests validated the success of inducing CKD accompanied by reproductive dysfunction in rats. YGY significantly retarded the CKD progression and improved the hormone levels of male CKD rats. Sexual behavior tests showed YGY can significantly improve CKD rats' sexual function. In addition, the pathological changes of the kidney and testis, sperm abnormality rate and sperm morphological abnormalities of the CKD rats were reduced by YGY. Furthermore, decreased expression of HIF1α and EPO, and increased expression of p-EPOR (Tyr368), p-JAK2 (Tyr570) and p-STAT5 (Ser725) were observed in the kidney and the testis of the CKD rats. The YGY extract dramatically increased the expression of HIF1α and EPO, and decreased the expression of p-EPOR (Tyr368), p-JAK2 (Tyr570) and p-STAT5 (Ser725) to regulate key proteins in the HIF1α-STAT5 pathway of the kidney and testis.

CONCLUSIONS

YGY has obvious reversal effects on the abnormal symptoms of adenine-induced CKD and the abnormal symptoms of rats with hypothyroidism and male reproductive hypotension. Its mechanism is related to its ability to regulate the HIF1α-STAT5 pathway.

Delayed Initiation of Hemodialysis in Pregnant Women with Chronic Kidney Disease: Logistical Problems Impact Clinical Outcomes. An Experience from an Emerging Country

BACKGROUND

Chronic kidney disease (CKD) is associated with reduction of fertility and increased complications during pregnancy. The aim of this work is to analyze the clinical outcomes and risk factors in pregnant women who needed to start dialysis with different schedules in a public hospital in Mexico City, with particular attention on the interference of social and cultural elements as well as resource limitations.

MATERIAL AND METHODS

CKD women who needed dialysis in pregnancy over the period 2002⁻2014 and had with complete demographic and outcome data were included in this retrospective study. Clinical background, renal function during pregnancy, dialysis schedule, and clinical outcomes were reviewed.

RESULTS

Forty pregnancies in women with CKD who needed dialysis in pregnancy (39 singleton and one twin pregnancy) were studied: All patients were treated with hemodialysis. Thirty-nine patients had CKD stages 4 or 5 at referral; only one patient was of stage 3b. Dialysis was considered as indicated in the presence of fluid overload, unresponsive hypertension in the setting of advanced CKD, or when blood urea nitrogen values were increased to around 50 mg/dL. However, the initiation of dialysis was often delayed by days or weeks. The main reason for delaying the initiation of dialysis was patient (and family) refusal to start treatment. All patients were treated with thrice weekly dialysis, in 3⁻5 hour sessions, with a target urea of <100 mg/dL. The number of hours on dialysis did not impact pregnancy outcomes. Ten pregnancies ended in miscarriages (8 spontaneous), 29 in pre-term delivery, and 1 in term delivery. Fifteen women were diagnosed with preeclampsia, one with eclampsia, and one with HELLP (hemolysis, elevated liver enzymes, low platelets,) syndrome. Twenty-four of the neonates survived (77.4% of live births); six singletons and one twin died as a consequence of prematurity. Two neonates displayed malformations: cleft palate with ear anomalies and duodenal atresia.

CONCLUSIONS

CKD requiring hemodialysis in pregnancy is associated with a high frequency of complications; in the setting of delayed start and of thrice-weekly hemodialysis, dialysis schedules do not appear to influence outcomes.