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SAN DIEGO -- When it comes to women's health, nephrologists expressed a lack of confidence in handling certain clinical scenarios, according to researchers here.

Among the 154 responders to a 25-item survey of Canadian and U.S. nephrologists, the majority felt they were not confident in their ability in managing a number of women's health-related issues in their kidney patients, reported Monica Reynolds, MD, of the University of North Carolina in Chapel Hill, at the American Society of Nephrology (ASN) Kidney Week 2018.

Also seen in the survey, less than 40% of nephrologists reported that they felt as though they had the confidence in contraception counseling, or in their ability to confidently refer patients for fertility therapy. Additionally, 64% and 68% reported they only provided contraception and pre-conception counseling to less than one woman per month, respectively.

"Nephrologists often assume a primary care provider role, and our patients expect us to be competent in women's health as it relates to chronic kidney disease [CKD]," Reynolds explained to MedPage Today. "Those who completed the survey cited reasons for not counseling, which included lack of training or little knowledge or confidence in the subject area."

"They [said they] felt that educational tools, such as case-based materials or continuing education sessions, would boost confidence, and we agree this might be a logical next step to provide relevant guidelines on topics across the spectrum of women's health," she added.

Of the 154 respondents, 58% were from the U.S., while 53% were women with a median age between 41-45. More than three-fourths identified their practice setting as academic, and 55% reported fellowship training in women's health, "which was similar across country of training (P=0.325)," the authors stated.

Among two of the top clinical scenarios that nearly all the nephrologists surveyed reported not feeling confident or very confident in included managing menstrual disorders, as well as diagnosing and managing menopause in their renal patients.

Between 60% to 80% of responders also did not feel confident in managing nephrotic syndrome in pregnancy, managing dialysis during pregnancy, or managing immunosuppressive medications while the patient was breastfeeding. In addition, 91% of these responders said they cared for less than five women who were pregnant while on dialysis.

"Despite low physician confidence, our results highlighted the changing practices in dialysis treatment time for pregnant women," said Reynolds. "We were pleasantly surprised that of the nephrologists who had managed at least one pregnant woman on dialysis, 98% reported adjusting dialysis intensity. Specified regimens included adjusting to 5-7 days of dialysis, utilizing nocturnal dialysis, or targeting 36 hours per week."

This likely stems from research demonstrating improved live birth rates and longer gestation in women receiving at least 36 hours of dialysis per week," she noted.

As for contraceptive counseling, "we anticipated that the frequency of contraception counseling would be low, but I think we were surprised at how low it was reported," said Reynolds. She added that, for most women, "protection from an unplanned pregnancy is a measure of quality of life and we believe this is no different for women with CKD."

"Given the commonly prescribed teratogenic medications in our field, including angiotensin converting enzyme inhibitors and angiotensin II receptor blockers, contraception counseling should be ubiquitous," she stated. "However, in the 12 months prior to taking the survey, 15% of nephrologists did not provide contraception/family planning counseling to any woman, and of those that counseled at least one woman, 58% counseled less than one woman per month on average."

Nearly half of Canadian nephrologists said they felt either confident or very confident in counseling women on pregnancy outcomes according to their CKD stage versus less than half of American nephrologists.

Diagnosing pre-eclampsia in women was the clinical scenario that the most nephrologists felt confident in managing, with nearly 60% of American and Canadian nephrologists responding affirmatively.

Gaining confidence in dealing with some of these clinical scenarios won't happened overnight, but confidence is more likely to grow from habitually engaging in discussions with patients, suggested Reynolds.

She recommended that "by taking the initiative to review family planning goals at each clinic visit, you can create an open and ongoing dialogue that emphasizes safety and preparation. Likewise, through discussing menstrual irregularities, you can proactively address treatment regimens that may be detrimental to kidney disease -- such as non-steroidal anti-inflammatory medications or an estrogen-containing birth control pill -- and advise alternatives."

"Finally, when initially evaluating a woman of child-bearing age, taking a detailed obstetric history is time well spent as this can aid in risk assessment for future pregnancies and chronic diseases including diabetes, hypertension, and cardiovascular disease," Reynolds said.

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