Understanding Kidney Issues in Females: Key Insights

1. How Kidney Disease Affects Women Differently 

 

Changing hormones increases the risk of autoimmune diseases like lupus nephritis. Other diseases, such as pregnancy complications, increase the risk of kidney disease, especially in women, differently than in men. Women are also less aware of kidney disease symptoms, which can delay diagnosis and treatment. Women have a higher incidence of chronic kidney disease (CKD), but men are at increased risk of kidney failure due to different hormonal influences. The following factors of kidney disease affect women directly. 

Hormonal Influence

Estrogen’s Role in Kidney Function

Sex hormones, especially oestrogens, play an essential role in kidney health. They protect premenopausal women and slow down the progression of CKD. When oestrogen hormones interact with the cells that make up the nephron and control several processes. For example, estrogens protect the kidneys by slowing down glomerulosclerosis and tubulointerstitial fibrosis. However, the decline of oestrogen hormones in post-menopausal women increases the risk of CKD. Thus, oestrogens have nephroprotective effects. 

Lower amounts of oestrogen and other hormones decline during menopause. It shows several symptoms, but primarily women only complain about the vasomotor symptoms, like hot flashes and night sweats. 

Pregnancy-Related Risks: Preeclampsia and CKD

Preeclampsia is a marker for an increased risk of subsequent ESRD. The National Institute of Health highlighted that preeclampsia occurs in 40% of pregnant females of advanced stages of CKD, with an increment in risk with increasing prepregnancy CKD stage (4 and 5). The NIH also highlighted that hypertensive disorders of pregnancy (HDP) increase the chances of CKD in mothers, especially CKD caused by high blood pressure or diabetes. The risk is higher after having preeclampsia before the baby or after the delivery. The symptoms worsen with being overweight before the pregnancy.

 

What are the stages of Chronic Kidney Disease depending on GFR?

 

The below table highlights the different stages of chronic kidney disease. 

CKD Stages	GFR (mL/min/1.73 m²)	Description	Symptoms	Progression
Stage 1	≥ 90	Usually asymptomatic with rare signs of kidney damage (e.g., hematuria or proteinuria)	Often asymptomatic.	Usually stable with appropriate management.
Stage 2	60 to 89	Mildly decreased GFR; evidence of kidney damage may be present	Mild fatigue; possible changes in urine output.	Generally slow; monitoring is essential.
Stage 3a	45 to 59	Mild to moderate decreased kidney function	Fatigue, fluid retention.	It can remain stable but requires monitoring and lifestyle adjustments.
Stage 3b	30 to 44	Moderate to severe reduced kidney function	More severe symptoms, including swelling and back pain.	Higher risk of complications; close monitoring is required.
Stage 4	15 to 29	Severe decreased kidney function	Nausea, vomiting, significant fatigue, increased risk of anaemia, and bone disease.	Close monitoring is required; progression may lead to severe complications.
Stage 5	Less than 15	Kidney failure may require dialysis or a transplant	Severe symptoms such as shortness of breath, swelling, and uraemia (buildup of toxins).	Critical stage: immediate intervention is often needed, including dialysis or transplant options.

Table 01: Stages of Chronic Kidney Disease

Autoimmune Vulnerabilities

Lupus Nephritis Prevalence

Lupus nephritis is an autoimmune condition more common in females. Systemic lupus erythematosus (SLE) affects almost any organ system, including the skin, joints, kidneys, blood cells, and nervous system. Typically, SLE is an uncommon condition but 90% of cases (1 in 1,000) occur in women, frequently starting at childbearing age.

Rheumatoid Arthritis and Sjögren’s Syndrome Connection

Similarly, rheumatoid arthritis (RA) is directly linked with Sjögren’s syndrome. Both diseases are autoimmune, and they share similar immune system dysregulation. Due to their autoimmune nature, they cause inflammation that may directly affect kidney tissue and lead to impaired kidney functions. Both conditions are more concerning in females, who are more susceptible to autoimmune conditions. These conditions are not always shown by symptoms but kidney involvement in RA and Sjögren’s syndrome may exhibit the following symptoms.

• proteinuria (excess protein in urine) 
• Hematuria (blood in urine) 
• Abnormal kidney function tests 
• Edema (swelling) due to fluid retention

Anatomic Factors

Shorter Urethra and UTI Risk

Some anatomic factors increase the risk of infection, especially in women. The most common causes of UTI among females are sex play, intercourse, and wiping from back to front after bowel movements. Women have shorter urethras than men, and bacteria travel shorter distances to reach the bladder. This makes women susceptible to UTI, and if left untreated, it may lead to chronic kidney damage. 

However, most UTIs only affect the bladder; if left untreated or recurrent UTIs, the infection ascends to the kidneys and causes a more severe condition, pyelonephritis, which may lead to kidney damage.

Why are UTIs dangerous for female kidneys?

When the females get UTI, they are at increased risk of kidney infection. An infection in the kidneys can start in either the urethra (the tube that sends urine out of the body) or the bladder. The bacteria might spread to one or both kidneys. 

A kidney infection or UTI needs to be treated immediately. If left untreated for a longer time, it damages the kidneys. If not, the bacteria can enter the bloodstream and cause a dangerous infection. In hospitals, healthcare providers usually prescribe antibiotics to treat UTIs and kidney infections. You can also follow these tips to maintain kidney health and prevent kidney infections.

Pelvic Floor Dysfunction and Urinary Retention

Urinary retention can be caused by problems with the pelvic floor, which are more common in women after childbirth. Chronic urine retention increases the risk of UTIs, which causes the swelling of the bladder and could damage the kidneys over time. To lower the risks, it is essential to treat pelvic floor problems with physical therapy and other methods.

According to research published in AHA journal, women who had preeclampsia are more likely to develop CKD than men post hypertension. This higher risk makes it more critical for gender-specific monitoring and preventive strategies among women with preeclampsia stages.

Research indicates that women who experienced preeclampsia are at a higher risk of developing CKD compared to men with a history of hypertension. This heightened risk emphasises the need for gender-specific monitoring and preventive strategies in women with a history of preeclampsia.

The Lupus Foundation of America also highlighted that 90% of people living with lupus are women. People who develop this age are mainly between the ages of 15 and 44. They experience common symptoms such as pain, fatigue, hair loss, cognitive issues, and physical impairments.

2. Kidney Disease Warning Signs Specific to Women 

Kidney disease in women causes several symptoms including changes in urine color, swelling, fatigue, and skin rashes.  Other symptoms also include

Subtle Early Symptoms

Fatigue

Fatigue is a common symptom of kidney disease. When the kidneys cannot function properly, waste products build up in the blood, causing tiredness and weakness. Sometimes, fatigue is misattributed to anemia or thyroid issues. A study published in PubMed Central also reported that a large percentage of people with CKD experience significant fatigue. 

Menstrual Irregularities

Menstrual irregularities due to hormonal imbalances are a common symptom in women with kidney disease. Poor kidney function disrupts the normal hormonal axis, which can cause irregular periods, increased bleeding, missed periods, or even early menopause. This is especially common in advanced stages of kidney disease, like end-stage renal disease (ESRD). 

Reproductive Health Clues:

• Pyelonephritis: Kidney infection is a type of UTI in which infection can travel from one or both kidneys, also known as pyelonephritis. The infection mostly starts with a bladder infection in the lower urinary tract, which causes an infection. Both kidney infection and UTI differ depending on several factors as highlighted below in the table.

 

Aspect	Urinary Tract Infections (UTIs)	Kidney Infections
Location	Affects the lower urinary tract (urethra and bladder)	Affects the upper urinary tract (kidneys)
Common Symptoms	Frequent urge to urinate Burning sensation during urination Cloudy or strong-smelling urine Lower abdominal pain	High fever Chills Nausea and vomiting Pain in the back, side, or groyne Symptoms of a UTI (frequent urination, pain)
Severity	Generally mild but uncomfortable; it usually doesn’t cause long-term damage.	More severe, it can lead to kidney damage or sepsis if left untreated
Treatment	Oral antibiotics Pain relievers Increased fluid intake	Stronger antibiotics (often IV in severe cases) Hospitalisation Longer treatment duration
Complications	Rare, but causes kidney infection if untreated	It can cause permanent kidney damage, high blood pressure, or sepsis
Who’s at Risk?	More common in women, especially those who are sexually active	Anyone with untreated UTI, urinary blockages, or weakened immune systems

Table 2: Difference Between UTIs and Kidney Infections

• Swelling: Swelling is another symptom of kidney disease, which is more common in normal gestation. Some fluid accumulation during pregnancy is normal, especially during the 3rd trimester. This condition is called edema. Oedema is linked to kidney disease, and usually occurs in the legs and around the eyes. If the body retains excess water, the kidneys are not working as well as they should. It is challenging to differentiate between regular changes during pregnancy and signs of kidney disease. However, women who notice uneven or long-lasting swelling, especially with other symptoms like high blood pressure or proteinuria, should immediately consult a doctor.

Underrecognised Red Flags:

Some symptoms such as foamy urine and hyperpigmentation are underrecognised red flags and females mostly ignore it by linking it with another disease.

Foamy urine (proteinuria) vs. UTI discharge confusion.

Another red flag sign that women usually ignore is foamy urine. Sometimes the foamy urine is normal and can be caused by concentrated urine. However, continuous foamy urine could be a sign of proteinuria, when protein leaks into the urine. It may be a sign of kidney failure. Many women often confuse foamy urine with discharge from urinary tract infections, so they might not take it seriously as a sign of kidney damage. Thus, it is essential to recognise this sign because doctors can diagnose early proteinuria as a symptom of kidney disease.

Hyperpigmentation from uremic toxins 

Hyperpigmentation is another symptom of kidney disease that results from uremic toxins. Increased melanin production, caused by the accumulation of β-melanocyte stimulating hormone due to decreased excretion from renal failure, causes it.

The National Institute of Health (NIH) also reported that some symptoms, such as menstrual abnormalities and shorter reproductive lifespan, are common in females with CKD. However, the menstrual health of females may be improved with kidney transplantation.

3. Kidney Failure Symptoms in Females 

Below are some indicators more common in females with CKD and renal failure.

Late-Stage Indicators:

Severe pruritus (itchiness) due to phosphate buildup

Uremic pruritus, or severe itching, commonly causes discomfort in patients with CKD and ESRD. The symptom often links to advanced stages of renal dysfunction and directly relates to the buildup of toxins in the blood. No skin rash causes the itching and is not specific to any body part. However, the itching can

• Come and go.
• Last throughout the day.
• Keep you up at night.
• It feels like it’s all over the body or may affect a specific body part.
• Get worse when the skin becomes dry.
• It affects mental health and decreases quality of life.

In renal failure, people on dialysis are more likely to experience uremic pruritus than those who are not on dialysis. The itchiness usually appears in large areas such as the back, face, and the shunt arm. Possible causes of uremic pruritus are a buildup of uremic toxins due to phosphate buildup, an imbalance of the immune system, nephropathy, or medications.

Uremic frost

"Uremic frost" is a rare skin condition in which tiny white crystalline urea deposits appear.  It shows severe kidney failure with high urea levels in the blood. The frost is a white or yellowish coating of urea crystals on the beard area and other parts of the face, neck, and trunk. The crystals are usually observed when sweat evaporates and leaves urea crystals. This sign is rarely observed due to early dialysis intervention and now rare in developed countries due to dialysis access.

 

Cognitive & Emotional Impact:

Dialysis dementia 

Dialysis dementia, a neurodegenerative condition, causes cognitive decline, personality changes, and other neurological symptoms. It also appears as dialysis encephalopathy syndrome when the aluminium content in the brain exceeds 9 mg/kg. Seizures, dementia, speech disorders, personality changes, dysarthria, dysphagia and ataxia characterise it.

People with end-stage renal disease on dialysis, newborns receiving TPN, and industrial workers exposed to aluminium all face a high risk of aluminium toxicity.

For dialysis patients using phosphate binders containing aluminium, common causes of toxicity include excessive aluminium intake through these binders and, historically, exposure to contaminated dialysis water. With improved technology, modern dialysis avoids aluminium-based phosphate binders, reducing toxicity risk. 

A study published in the Clinical Journal of the American Society for Nephrology Research shows that women on dialysis are more likely than men to develop dialysis dementia. It also highlighted that a higher percentage of female patients are diagnosed with dementia within a specific timeframe. It may be due to biological factors and possibly variations in access to healthcare or reporting behaviors.

Postmenopausal depression exacerbated by CKD.

Depression is another common symptom experienced by women with CKD after menopause. Menopause is a natural stage of life. It results due to low estrogen levels and symptoms of kidney disease, such as tiredness, trouble sleeping, and a general lower quality of life that is similar to signs of depression.

Some kidney diseases, like autosomal dominant polycystic kidney disease (ADPKD), may get worse during menopause. It is influenced by hormonal balances that may be disrupted in menopause. Antidepressants are helpful to manage the psychological symptoms of the menopause. Some symptoms of menopause linked with kidney disease include

• low mood
• irritability
• anxiety
• forgetfulness
• difficulty concentrating (‘brain fog’)

Pregnancy and Kidney Failure:

Kidney disease can worsen during pregnancy, and pregnancy also puts stress on the kidneys. The condition can affect both the fetus and the mother. During pregnancy, the kidneys experience marked haemodynamic, renal tubular, and endocrine changes. Most women with chronic kidney disease who get pregnant have mild kidney failure, and pregnancy doesn't usually change the outlook for their kidneys. However, women with severe renal impairment find it challenging to conceive, with the highest rates of miscarriages, and the worst pregnancy outcomes.

Higher Risk of Miscarriages

The Davita Kidney Care also highlighted that 1 to 7% of women of childbearing age on dialysis can get pregnant. Moreover, 90% of women of childbearing age on dialysis can't get pregnant because kidney disease hinders their ability to produce healthy eggs for fertilisation.

They also highlighted that conceiving while on dialysis is very uncommon. Around 20% of these pregnancies end in miscarriages. A normal pregnancy lasts for 40 weeks, but about 80% of kidney pregnancies only last for 32 weeks, resulting in premature birth.

Ethical dilemmas in transplantation during childbearing years.

Ethical dilemmas in transplantation during childbearing years mainly involve how the procedures might affect a woman's ability to have children in the future. It also considers how to make decisions about organ donation while taking into account the woman's reproductive goals, and the allocation of organs when a woman needs a transplant while she is pregnant or planning to become pregnant. Thus, it raises concerns about potential risks to both the mother and the baby. 

According to the 2023 USRDS report, women on dialysis generally have lower survival rates compared to men.

Take a 60-minute quiz break to determine whether your kidneys are working properly or if you are at higher risk for kidney disease.

Frequently Asked Questions

Can birth control pills harm kidneys?”

Yes, hormonal birth control may affect kidney function. Mainly, birth control pills don't directly harm the kidneys. However, combined oestrogen pills (which contain both oestrogen and progesterone) can worsen hypertension in some people. In this case, taking only progesterone pills is a safer option for people to take in high blood pressure. Always consult with your doctor to find the best birth control method for your specific birth requirements.. 

Does PCOS affect kidney health?

A study published in the Journal of Clinical Endocrinology & Metabolism highlighted a possible link between PCOS and kidney health issues due to its association with insulin resistance. However, current studies do not conclude that PCOS directly causes chronic kidney disease (CKD). According to NIH, research indicates that women with PCOS may not have a significantly higher risk of developing CKD compared to healthy women. They found that PCOS is associated with type 2 diabetes, obesity and hypertension, which may increase the risk of CKD. 

Are kidney stones a warning sign for women?

Yes, kidney stones can serve as a warning sign for women. Recurrent stone formation directly increases the risk of developing chronic kidney disease (CKD), especially for women with metabolic syndrome.