Risk of Adult Hypertension in Offspring From Pregnancies Complicated by Hypertension: Population-Based Estimates.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) have been associated with an increased risk of chronic hypertension for both mothers and offspring. We sought to quantify the incidence of chronic hypertension in offspring from HDP-affected pregnancies in a large, population-based cohort study. Furthermore, we evaluate the association of HDP exposure in utero and maternal chronic hypertension in offspring. METHODS: We performed a population-based cohort study of 8755 individuals born during 1976 to 1982 to 7544 women who all resided in the same community at the time of delivery. HDP were identified using a previously validated algorithm. Diagnosis of chronic hypertension in mothers and their offspring was determined using diagnostic codes. Cox proportional hazards regression was used to assess the association between HDP and chronic hypertension. RESULTS: HDP exposure (hazard ratio, 1.50 [95% CI, 1.18-1.90]) and maternal chronic hypertension (hazard ratio, 1.73 [95% CI, 1.48-2.02]) were both associated with a significant increased risk for chronic hypertension in offspring. Both risk factors remained significantly associated with increased risk of hypertension in offspring when included together in a multivariate model. Having both exposures was associated with a 2.4-fold increase in the risk of hypertension in offspring, suggesting a synergistic additive interaction. CONCLUSIONS: HDP exposure in gestation and maternal hypertension are both independently associated with an increased risk of chronic hypertension in offspring. Our results suggest that HDP exposure in utero, in addition to maternal chronic hypertension, may lead to a greater risk for the development of hypertension in offspring.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications.

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Physician Identification Badges: A Multispecialty Quality Improvement Study to Address Professional Misidentification and Bias.

OBJECTIVE: To evaluate whether providing resident physicians with "DOCTOR" role identification badges would impact perceptions of bias in the workforce and alter misidentification rates. PARTICIPANTS AND METHODS: Between October 2019 and December 2019, we surveyed 341 resident physicians in the anesthesiology, dermatology, internal medicine, neurologic surgery, otorhinolaryngology, and urology departments at Mayo Clinic in Rochester, Minnesota, before and after an 8-week intervention of providing "DOCTOR" role identification badges. Differences between paired preintervention and postintervention survey answers were measured, with a focus on the frequency of experiencing perceived bias and role misidentification (significance level, α=.01). Free-text comments were also compared. RESULTS: Of the 159 residents who returned both the before and after surveys (survey response rate, 46.6% [159 of 341]), 128 (80.5%) wore the "DOCTOR" badge. After the intervention, residents who wore the badges were statistically significantly less likely to report role misidentification at least once a week from patients, nonphysician team members, and other physicians (50.8% [65] preintervention vs 10.2% [13] postintervention; 35.9% [46] vs 8.6% [11]; 18.0% [23] vs 3.9% [5], respectively; all P<.001). The 66 female residents reported statistically significantly fewer episodes of gender bias (65.2% [43] vs 31.8% [21]; P<.001). The 13 residents who identified as underrepresented in medicine reported statistically significantly less misidentification from patients (84.6% [11] vs 23.1% [3]; P=.008); although not a statistically significant difference, the 13 residents identifying as underrepresented in medicine also reported less misidentification with nonphysician team members (46.2% [6] vs 15.4% [2]; P=.13). CONCLUSION: Residents reported decreased role misidentification after use of a role identification badge, most prominently improved among women. Decreasing workplace bias is essential in efforts to improve both diversity and inclusion efforts in training programs.

The Effect of Gender-Affirming Hormone Therapy on Serum Creatinine in Transgender Individuals.

OBJECTIVE: To describe the changes in serum creatinine (Cr) levels after the initiation of gender-affirming hormone therapy (GAHT) in transgender individuals to better understand the expected changes and interpretation of laboratory values in this population. METHODS: A retrospective chart review of all adult transgender patients initiated on GAHT at Mayo Clinic from January 2011 to October 2019 was completed. Laboratory values were obtained prior to initiating GAHT and at 3, 6, and 12 months after initiating GAHT. Baseline Cr values were compared with Cr values at 3, 6, and 12 months after initiating GAHT in transgender men (TM) on testosterone and transgender women (TW) on estradiol and antiandrogens. RESULTS: A total of 84 TW (median age of 30 years) and 24 TM (median age of 23 years) were included for analysis. Following a matched pair analysis of TW, Cr values were found to be significantly decreased by -0.03 at 3 months (P = .04), -0.10 at 6 months (P < .01), and -0.07 at 12 months (P < .01) compared with baseline values. Following a matched pair analysis of TM, Cr values were found to be significantly increased, on average, by 0.14 at 3 months (P = .04), 0.21 at 6 months (P = .016), and 0.15 at 12 months (P = .003) compared with baseline values. CONCLUSION: In TW and TM, a change in Cr level was seen as early as 3 months toward their affirmed gender after initiating GAHT. Clinicians can use Cr levels established at 6 months as new baseline values, as these changes continue to persist up to 12 months.

Pregnancy, Contraception, and Menopause in Advanced Chronic Kidney Disease and Kidney Transplant.

Background: Reproductive health is an essential part of the care of women with kidney disease. However, the self-reported patient experience of reproductive issues has been underexplored. Materials and Methods: We identified a cohort of women ages 18 to 44 at the time of kidney transplant from 1996 to 2014 at our 3-site program (n = 816). We sent each woman a survey on her reproductive lifespan, characterizing features from menarche to menopause. Results: We received survey responses from 190 patients (27%). One third of respondents reported amenorrhea before transplant, and 61.5% of these women reported resumption of menses post-transplant. The average age of menopause was 45.5 years, earlier than the general population (51.3 years). There were 204 pregnancies pretransplant and 52 pregnancies post-transplant. Pregnancies post-transplant were more likely to be complicated by preeclampsia, preterm delivery, and small for gestational age babies than pregnancies that occurred >5 years before transplant. Pregnancies <5 years before transplant were similar to post-transplant pregnancies with respect to complications. Forty-two percent of women were advised to avoid pregnancy after transplant, most often by a nephrology provider. Conclusions: In our cohort of kidney transplant recipients, women report increased pregnancy-related complications post-transplant and in the 5 years before transplant, compared with pregnancies that occurred greater than 5 years before transplant. They were often counseled to avoid pregnancy altogether. Women reported a younger age of menopause relative to the general population. This should be considered when counseling patients with chronic kidney disease regarding optimal pregnancy timing.

Hypertensive Disorders of Pregnancy.

Hypertensive disorders of pregnancy are increasing in incidence and are major causes of maternal morbidity and mortality both in the United States and worldwide. An understanding of these diseases is essential for the practicing nephrologist, as preexisting kidney disease is an important risk factor. In addition, the development of hypertensive disorders of pregnancy has important implications for long-term risk of kidney disease and cardiovascular disease. The definition and diagnostic criteria has changed in recent years as our understanding of the disease entity has progressed. Currently, proteinuria is no longer a necessary diagnostic feature of preeclampsia. Preeclampsia and gestational hypertension may develop through multiple different mechanisms. Current research suggests contributions of both placental factors and maternal factors contribute to the disease and represent different phenotypic presentations of preeclampsia.

Parental health in fellowship trainees: Fellows' satisfaction with current policies and interest in innovation.

BACKGROUND: Parenthood during medical training is common and impacts trainee well-being. However, current graduate medical education parental health policies are often limited in scope. We explored current fellowship trainees' knowledge of/satisfaction with current policies as well as interest in potential changes/additions to existing policies. METHODS: Fellowship program directors/coordinators at a three-site academic institution were surveyed and information was collected from 2015 to 2019 regarding fellow demographics and parental health policies. We distributed an electronic survey to fellows containing Likert-type-scale questions rating knowledge/level of satisfaction with current parental health policies and interest in potential additions/modifications to current policies. RESULTS: Thirty-five of 47 (74%) fellowship programs responded. An average of 11% of female fellows and 15% of male fellows took parental leave during the study period. Three (9%) of the programs had at least one additional parental health policy beyond institutional graduate medical education policies. In the fellow survey, 175 of 609 fellows responded (28.7%), of which 84 (48.6%) were female. Although 89.1% agreed/strongly agreed that parental health is an important part of health and well-being for fellows, only 32% were satisfied/very satisfied with current policies (no significant sex-related differences). Fellows reported the following potential interventions as important/very important: 79.2% increased (paid) maternity leave (72.7% male, 86.7% female, p = 0.02), 78% increased (paid) paternity leave (76.4% male, 81.9% female, p = 0.37), 72.3% part-time return to work (60.2% male, 84.3% female, p = 0.0005), 63% coverage for workup/management of infertility (52.3% male, 74.7% female, p = 0.002), and 79.9% on-site day care (70.7% male, 89.2% female, p = 0.003). CONCLUSIONS: Parental health includes multiple domains, not all of which are covered by current policies. Fellows feel that parental health is an important part of overall health and well-being, but most are not satisfied with current policies. Expanded access to parental leave and new policies (part-time return to work, infertility management, and on-site day care) are opportunities for innovation.

The role of kidney biopsy in diagnosis of preeclampsia in kidney transplant patients.

OBJECTIVE: The aim of this report is to review two patients who developed proteinuria in pregnancy after kidney transplant in order to highlight the importance of maintaining a broad differential and the diagnostic utility of kidney biopsy in this clinical scenario. METHODS: Two cases of women with kidney transplants who presented with proteinuria in pregnancy are described and the literature is reviewed. RESULTS: In both cases, a kidney biopsy allowed for prompt diagnosis and treatment. CONCLUSION: Kidney biopsy should be considered an important diagnostic tool in this clinical scenario. ABBREVIATIONS: ACE: angiotensin-converting enzyme; ESKD: end-stage kidney disease; FSGS: focal segmental glomerulosclerosis; RAAS: renin aldosterone angiotensin system.

Effects of age, parity, and device type on complications and discontinuation of intrauterine devices.

OBJECTIVE: To conduct an analysis of intrauterine device (IUD)-related outcomes including expulsion, contraceptive failure, and early discontinuation and to compare these outcomes in regard to age, parity, and IUD type. METHODS: This was a multicenter retrospective chart review of adolescents and women aged 13-35 years who had an IUD inserted for contraception between June 2008 and June 2011. RESULTS: A total of 2,523 patients' charts were reviewed. Of these, 2,138 patients were included in our analysis. After a mean follow-up of 37±11 months, the overall rates of IUD expulsion and pregnancy were 6% and 1%, respectively, and were not significantly different by age or parity. Intrauterine device discontinuation rates were 19% at 12 months and 41% after a mean follow-up of 37 months. Despite similar rates of IUD discontinuation between age groups at 12 months of use, teenagers and young women aged 13-19 years were more likely to request early discontinuation at the end of the total follow-up period. No significant difference was noted in pelvic inflammatory disease rates (2%) based on age. After adjusting for age and parity, we found that copper IUD users were more likely to experience expulsion and contraception failure compared with levonorgestrel intrauterine system users (hazard ratios 1.62, 95% confidence interval [CI] 1.06-2.50 and hazard ratios 4.89, 95% CI 2.02-11.80, respectively). CONCLUSION: Similar to adults, IUD use in adolescents and nulliparous women is effective and associated with low rates of serious complications. Health practitioners should therefore consider IUDs for contraception in all females. Teenagers and young women are more likely to request premature discontinuation of their IUDs and may benefit from additional counseling.