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Dr. Michelle Hladunewich is the Division Director, nephrology and obstetrical medicine, at Sunnybrook Health Sciences Centre in Toronto. She is also the Medical lead, glomerulonephritis and specialty clinics, with the Ontario Renal Network. Dr. Hladunewich has helped hundreds of women with kidney disease have children despite the risks.

Why did you choose to become a nephrologist?
Why I fell in love with nephrology, why I am a nephrologist, is because it is probably the only specialty where you can build the patient relationships that you have. In nephrology, you often see patients for many years, and get to know them personally. I really like that. I like knowing not just about my patient’s medical condition, but also about their families, and their aspirations. Nephrology is one of the few specialties that really affords you such a close relationship with your patients.

How did you come to specialize in helping women with kidney disease have children?
I am a big believer in hope. This is a disease that is chronic, and you need to try to build the best life you can with it. When I first started out in nephrology, it was a very male specialty. Women with kidney disease were often told, “It is not a good idea to have a child”. That is not a wrong statement, but that kind of advice is not particularly helpful to women. The answer doesn’t need to be no; the answer can also be when, and how. Nephrologists should outline the potential risks and empower women to make their own decisions on whether to move forward with a pregnancy.

What are the challenges women with kidney disease face trying to have a child?
There are challenges at every life stage when it comes to making decisions on reproductive health. Even something as simple as a birth control pill can hasten the progression of the underlying disease. Also, some of the renal drugs can impact fertility. There are some women who come to my clinic with very advanced kidney disease. They have to decide whether to try to have a baby right away, on dialysis, or after a kidney transplant. With all of those choices, there are many unknowns.

Why is it important to bring more attention to this issue?
It is really critical. Women need to know how to advocate for themselves. A recent survey found that less than 20 percent of nephrologists in Ontario were “very comfortable” with pre-pregnancy and pregnancy counselling of women with kidney disease. Most were just “somewhat comfortable.’ Nephrologists may not bring up discussions around reproductive issues with patients. Women need to be aware of the risks and issues around pregnancy, so they can make informed choices for themselves.

What kind of advances have we seen in recent years?
I think there is much more awareness in the nephrology community that women with kidney disease can have successful pregnancies. When babies are born pre-term, they are now doing better due to advances in neonatal care. There is also a better understanding of pre-eclampsia, which is one of the most significant diseases that affect women with CKD during pregnancy. Probably the biggest change is for women on dialysis. Physicians are now realizing that you can have a baby on dialysis. It is a really difficult road, but more women are able to do that. It also gives women with more advanced CKD – the ones most at risk of complete kidney failure -- the option of continuing their pregnancy on dialysis.

What do you find most worthwhile about your work?
My patients. Having my patients come into the clinic with their children is the best feeling in the world. Seeing moms with kidney disease deliver healthy babies – that can keep you going forever.