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Having children

    1. Can men with kidney failure father children?

Yes, but men with kidney diseases may have a reduced sperm count and have difficulty fathering a child.

A man’s ejaculate contains millions of sperm, each one looking like a microscopic tadpole. The sperm move around, and one needs to reach an egg in the woman for conception (fertilsation of the egg) to occur. Sperm can be examined under a microscope, and the quality of the sperm measured by the numbers of the sperm (the ‘sperm count’), their ability to move, and the numbers with abnormal shapes. A number of research studies have looked at the sperm of men with kidney diseases.

Kidney disease which is not severe enough to give kidney failure or to need dialysis probably does not affect a man’s sperm count. Studies looking at the sperm of men receiving dialysis treatment do show that many men have reduced sperm counts, and the sperm that are present are underactive. This seems to be due to failure of the sperm to develop in the testicle. Sometimes there is associated testosterone deficiency, but it is not clear from research whether testosterone treatment restores the numbers and function of sperm in men with kidney failure.

After successful kidney transplantation, sperm numbers generally rise and there are reports of men who were infertile whilst on dialysis fathering children after transplantation.

    1. Pregnancy with kidney failure and on dialysis

There is a reduced success rate for pregnancy if a woman has advanced kidney failure or is on dialysis.

There are so many kidney diseases, that it is not possible to predict every possibility, so a woman wanting information should ask her own specialist. However, there are some generalisations that can be made.

  1. Minor kidney disease

    Minor kidney disease usually does not affect pregnancy at all. If a woman has normal kidney function and normal blood pressure with little or no protein in the urine, a pregnancy may proceed perfectly normally. An exception is in some women with a condition called lupus Click here for information on Lupus & Pregnancy)

  2. High blood pressure, normal kidney function

    If a woman has high blood pressure, this is likely to get worse during pregnancy. Without careful monitoring this could cause problems to the child and mother. A woman with high blood pressure before pregnancy is very likely to deliver prematurely, because of a rise in blood pressure during later pregnancy.

  3. Reduced kidney function

    If a woman has reduced kidney function, the risks of pregnancy and the chances of successful outcome are reduced. If the reduction in kidney function is not major (say, a woman has half or more of normal kidney function, with a blood creatinine level of about 150 micromoles per litre), pregnancy is usually successful. However, once kidney function is down to a quarter or less of normal (with a blood creatinine level of about 300 micromoles per litre), there are likely to be more problems with high blood pressure and premature delivery. In addition, the kidney function in the mother may get worse during or just after the pregnancy. In extreme cases dialysis may need to be started.

    The timing of pregnancy may need some planning for a woman with progressive kidney disease. It may be best to have a child whilst kidney function is quite good (say one half of normal). Waiting until kidney failure is advanced increases the risks, and some women decide to delay pregnancy until after they have received a kidney transplant, because of the risks to their own kidney function and because pregnancy on dialysis has a low success rate.

Medication and planning pregnancy

If a woman with kidney disease is planning a pregnancy, they should mention this to their medical team so that discussions can be had in advance.  One important area for review will be medication.  Even if someone is taking a number of drugs for high blood pressure and other problems, it is possible to have a successful pregnancy with little extra risk.  However, some drugs are safer than others and it may be best to make some changes to medication before getting pregnant.  Many kidney units now have special clinics where a kidney specialist and an obstetrician (doctor who specialises in childbirth) work together and can give the best advice.

Pregnancy whilst on dialysis

Women of childbearing age do not often get pregnant whilst on dialysis. This is because dialysis only replaces a small percentage of kidney function, so the body still has high levels of waste products, which interfere with egg production and the menstrual cycle. Once a woman becomes pregnant, high blood pressure almost always causes problems, leading to premature delivery.

In one study performed in the United States, 1.5% (between one and two in a hundred) of young women on dialysis became pregnant in a two year period. Half the pregnancies resulted in the birth of a live child. There were many miscarriages in early pregnancies, and some stillbirths. All living babies were born prematurely.

It is usually recommended that a woman on dialysis who is pregnant should have an increased dialysis dose, be monitored carefully for high blood pressure, and should have a good haemoglobin level maintained with erythropoeitin.

Women who want to have children should consider whether it would be better to use contraception whilst on dialysis, and plan to have children after a kidney transplant. While there are still risks, the likelihood of a successful pregnancy rises to over 70% (seven out of ten) from about 50% (five out of ten) on dialysis. Some women also feel that they would be better able to care for a child if they had a kidney transplant, rather than being on dialysis.

    1. Pregnancy after transplantation

Women can successfully have children if they have a functioning transplant, though there are some risks. Women are usually advised not to get pregnant in the first year after a kidney transplant. The drugs used to stop rejection of the kidney transplant need to continue to be taken during pregnancy

Key Points

  • Sex life is usually better after a transplant than on dialysis
  • For men who have trouble getting erections there are several treatments that can be used, including Viagra
  • Women can have babies after a transplant (all women child bearing age must have a pregnancy test prior a transplant)
  • Pregnancy can be complicated in transplant patients, but is usually successful
  • Pregnancy should be planned,
  • Speak to your Doctor: some drugs can potentially cause birth defects (eg mycophenolate: both women and men who have had a transplant need to change medications)

Sex is usually better after a transplant than on dialysis. The high level of waste that is present in the body before a transplant goes down to more normal levels and the body can work much better. However, a good sex life is not guaranteed. There may have been serious problems on dialysis that cannot be reversed. Diabetes, or stress, or side effects of drugs can affect sex drive. The doctors in the transplant clinic will be able to advise on ways in which sex life may be improved after a transplant.

Immediately after a transplant, sex would probably not damage the kidney, but it may be sensible to refrain from sex for a few weeks.

In women, fertility can return very quickly after a transplant, so contraception should be used straight away. The oral contraceptive can be taken safely by most women, but it may be better to use a barrier method (eg condoms) as doctors may advise delaying starting the oral contraceptive until after the first few months of transplantation.

Viagra

For men who have difficulty getting or maintaining erections, Viagra may be successful and has been used by many transplant patients. However, it may not be safe in some patients with heart problems. If Viagra is not safe to use, there are other treatments to help get erections, which may involve injections into the penis, or squirting a drug into the opening at the end of the penis.

A specialist on impotence can advise, and will also check that there are not other causes of impotence (such as testosterone deficiency) that can be treated.

Pregnancy after transplant

Fertility should return to normal after a transplant. This is particularly important for women, because it is very rare to have a successful pregnancy whilst on dialysis.

Many women do not menstruate on dialysis and usually menstruation returns after a transplant, although the periods may be irregular for many months.

It is not recommended that women get pregnant in the first year after a transplant. Pregnancy can cause problems with the levels of anti-rejection drugs and raised blood pressure, so it is better if the transplant has a chance to get well ‘settled in’ before getting pregnant.

A common worry is that the drugs given to prevent rejection and all the other problems of transplantation will cause damage to the baby. Perhaps surprisingly, this is not a major problem. Research has shown that there may be a higher early miscarriage rate in transplant women than in the general population, but that the live babies born to transplant mothers have no higher a risk of abnormalities than those born to ‘normal’ people. An exception to this is mycophenolate, and anyone planning a pregnancy (women or man) who is taking this drug should discuss the options for changing this drug with their transplant unit. Indeed, any woman planning a pregnancy after transplantation should discuss their drugs with the transplant unit. Many units also have a specialist clinic where a kidney specialist and an obstetrician work together, giving the best advice.

It is rare for the pregnancy to cause transplant failure, though the blood pressure generally goes up and blood levels of cyclosporin will fall, meaning the dose taken has to be increased. Sometimes the transplant function will be permanently reduced after pregnancy.

The blood pressure often goes quite high at about 34 weeks of pregnancy, resulting in a slightly premature delivery of the baby. However, so long as this is anticipated there are usually no serious problems. This is one of the reasons transplant units usually suggest the delivery takes place in the same hospital as the transplant unit, where there is more experience of transplanted women with pregnancies.

Breast feeding may not be possible after delivery – it depends on the drugs being taken for the transplant. Cyclosporin comes through the body into breast milk, so if the mother is taking this drug, the baby will have to be bottle fed, unfortunately.

    1. Are children of kidney failure patients healthy, should their kidneys be checked?

There are two problems to consider:

    • Are birth defects more common in the children of parents with kidney diseases?

Generally, even though parents may be taking several different types of medication, children born do not have excessive rates of abnormalities. However, the spontaneous miscarriage rate in early pregnancy may be higher than in normal people. 

Most babies are normal, and this is also the case for children born to parents if one of them has kidney disease. There is some research suggesting that there may be a higher miscarriage rate in kidney patients, especially in women with kidney transplants, but the babies that are born do not have a rate of birth defects higher than in normal people.

Drugs are used to treat people with kidney problems, and there is often concern that the drugs might cause birth defects. Research has been carried out with all the commonly used drugs in kidney patients; problems do not seem to occur commonly. However, if a pregnancy is to be planned, it is sensible to ask your doctor in advance about any changes in drug therapy that might be sensible.

Some of the newer anti-rejection drugs have not been in use for long enough to be sure of their safety in pregnancy.  In particular, women taking mycophenolate have a high risk of carrying a child with birth defects if they get pregnant whilst taking mycophenolate.  Check with your doctor for the most up to date information.

Could the baby have inherited kidney disease, and what checks should be performed on the baby?

Some kidney diseases can be inherited, others do not seem to be. Therefore it is important to know what caused your kidney disease in the first place (though doctors cannot tell what caused kidney failure in many people). Many types of kidney disease are not fully understood, and if more than one person in the family has kidney failure, it may be sensible to check children for kidney diseases.

Although research is showing the precise genetic problem that causes some inherited conditions, this does not mean that genetic testing on a blood sample or tissue sample can tell whether someone has a condition, or is a carrier. Often research has shown that several different genetic abnormalities can cause the same clinical condition, making testing difficult. Ask your specialist whether genetic testing is possible in your case.

Here is a brief list of kidney diseases and links to further information:-

  • Polycystic Kidney Disease - runs in families, for information Add link
  • Reflux Nephropathy - can be inherited, for information Add link
  • Alport’s syndrome - runs in families, for information Add link
  • Diabetes - kidney failure due to diabetes does not generally run in families, though a tendency to diabetes can be inherited. No testing of children for kidney disease is required.
  • Glomerulonephritis - does not usually run in families, but if there is more than one person in a family with glomerulonephritis, screening should be considered. Talk to your doctors and see if testing is advisable. A urine test for blood or protein should detect glomerulonephritis. For more information on glomerulonephritis in adults, Click here
    • Kidney disease developing during pregnancy in previously healthy women

    Kidney disease can be diagnosed during pregnancy. The most common problem is urine infection, which can be treated with antibiotics. Minor kidney diseases which may have been present for years before pregnancy can be detected because careful medical checks are performed during pregnancy. Less commonly, kidney diseases can develop for the first time during pregnancy. Lastly, a condition called ‘eclampsia’ can develop which causes high blood pressure and kidney failure in previously healthy women

    Urine infection

    Urine infections are common during pregnancy. One of the reasons for this is that the baby lies above the bladder, and can reduce the flow of urine from the kidneys to the bladder. A urine infection usually causes pain when passing urine, and a need to go more often. The urine may be cloudy or smelly. In more severe infections, there may be a temperature and pain in the upper back, over the kidney.

    A urine infection should be treated by increasing the amount of fluid a woman is drinking and by a course of antibiotic. There are several antibiotics that have been used extensively in pregnant women, and do not cause any side effects in the baby.

    If urine infections occur repeatedly in pregnancy, it may be necessary to get a scan of the kidneys, using an ultrasound (sound wave) scanner – this is the same machine used to scan the baby. The scan would be performed to make sure there are not kidney stones or kidneys affected by disease early in childhood. A scan would be expected to show back pressure on the kidneys during pregnancy (the medical term is hydronephrosis), this goes back to normal after pregnancy.

    Rarely, a woman needs to take daily low dose antibiotics during pregnancy.

    Minor kidney disease

    Minor kidney diseases are common and a woman may have a condition for years without knowing about it. Because of checks performed during pregnancy, this condition may come to light for the first time. Extra blood tests and a kidney scan will be performed, and often a kidney specialist will be asked to give an opinion. However, if the kidney disease is minor, it usually does not affect the pregnancy. In some cases there could be a higher risk of high blood pressure near the end of pregnancy.

    Kidney disease developing during pregnancy

    Occasionally a new kidney disease develops during pregnancy. This is rare. Lupus may develop for the first time during, or just after, a pregnancy.

    Eclampsia

    Women who are pregnant all have regular urine tests for protein, and regular measurement of their blood pressure. The reason for this is to detect any signs of a condition known as eclampsia. The early stages are called pre-eclampsia.

    In pre-eclampsia there is protein in the urine and high blood pressure. There may be some headaches, but often a woman feels very well. This usually occurs near the end of pregnancy. Treatment for pre-eclampsia is important to prevent progression to eclampsia, where there is very high blood pressure with kidney failure and fits (convulsions).

    A woman with pre-eclampsia is usually advised to rest and to take drugs to reduce the blood pressure. There are a number of drugs to reduce the blood pressure that have been shown to be safe for the baby. Intensive out-patient monitoring, or sometimes admission to hospital, are required. Nearly everyone with pre-eclampsia responds to treatment. If treatment is not working, it may be best to deliver the baby prematurely, because pre-eclampsia goes away when the woman is no longer pregnant.

    Kidney failure from eclampsia is very rare, occurring at a rate of less than 1 in 5000 pregnancies in the United Kingdom. When it does occur, delivery of the baby is imperative, and Caesarian section may be performed. Dialysis (artificial kidney) treatment may be necessary if the kidney failure is complete. Kidney function usually returns after a few days or two to three weeks. Very, very rarely the kidneys may be so damaged that they do not recover function, and the woman needs long term dialysis or a kidney transplant.

    A woman who has had pre-eclampsia or eclampsia is at increased risk of developing it again during another pregnancy. The possible risks of pregnancy should be discussed with doctors. Many women who have had pre-eclampsia have further pregnancies without problems, but careful monitoring throughout pregnancy is essential.

    The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.