Prescription of hormone replacement therapy in postmenopausal women with renal failure

Comparison of the Surgical Resection and Infarct 5/6 Nephrectomy Rat Models of Chronic Kidney Disease

The 5/6 nephrectomy rat remnant kidney model is commonly employed to study chronic kidney disease (CKD). This model requires removal of one whole kidney and two-thirds of the other. The two most common ways of producing the remnant kidney are surgical resection of poles, known as the polectomy (Pol) model, or ligation of upper and lower renal arterial branches, resulting in pole infarction (Inf). These models have much in common, but also major phenotypic differences, and thus respectively model unique aspects of human CKD. The purpose of this review is to summarize phenotypic similarities and differences between these two models and their relation to human CKD, while emphasizing their vascular phenotype. In this article we review studies that have evaluated arterial blood pressure, the renin-angiotensin-aldosterone-system (RAAS), autoregulation, nitric oxide, single nephron physiology, angiogenic and anti-angiogenic factors, and capillary rarefaction in these two models. Phenotypic similarities: both models spontaneously develop hallmarks of human CKD including uremia, fibrosis, capillary rarefaction, and progressive renal function decline. They both undergo whole-organ hypertrophy, hyperfiltration of functional nephrons, reduced renal expression of angiogenic factor VEGF, increased renal expression of the anti-angiogenic thrombospondin-1, impaired renal autoregulation, and abnormal vascular nitric oxide physiology. Key phenotypic differences: the Inf model develops rapid-onset, moderate-to-severe systemic hypertension, and the Pol model early normotension followed by mild-to-moderate hypertension. The Inf rat has a markedly more active renin-angiotensin-aldosterone-system. Comparison of these two models facilitates understanding of how they can be utilized for studying CKD pathophysiology (e.g., RAAS dependent or independent pathology).

A review and perspective on the assessment, management and prevention of fragility fractures in patients with osteoporosis and chronic kidney disease

This article aims to review the methods used for the assessment of fracture risk and the use of osteoporosis medications for fracture prevention in the population with CKD, and highlights the difficulties faced by clinicians in the management of these patients and the latest recommendations and guidelines. Chronic kidney disease (CKD) and osteoporosis often co-exist in older adults, and they present a major healthcare challenge. CKD mineral and bone disorder (CKD-MBD) occurs as renal function declines and this syndrome affects most patients in CKD stages 4 and 5. The biochemical abnormalities of CKD-MBD, renal bone disease and risk factors associated with age-related bone loss and osteoporosis lead to a cumulative effect on fracture risk and mortality. There is a need for routine evaluation of fracture risk and fracture prevention in this population. Measurement of bone mineral density (BMD) and the use of the FRAX tool have predictive value for incident fractures in the general population and in CKD. This enables physicians to identify CKD patients most at risk of sustaining a fragility fracture and allows a more targeted approach to fracture prevention. Data analysis from the pivotal trials of therapeutic agents used in osteoporosis show that these drugs can be considered in mild and moderate CKD (stages 1-3 CKD). Off-label drug use in patients with CKD-MBD and more severe renal impairment (CKD stages 4 and 5) could offer significant benefits to sub-groups of patients when carefully tailored to each individual's bone turnover and calcium and phosphate balance. However, this requires a selective approach and treatment decisions based on inference from pathophysiology while we await further trials. Guidelines advocate the correction and/or reduction of the biochemical abnormalities of CKD-MBD before initiation of treatment with osteoporosis drugs and close monitoring during treatment.

Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update

Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.

Estradiol and mortality in women with end-stage kidney disease

BACKGROUND

Young women with end-stage kidney disease (ESKD) have early menopause compared with women in the general population and the highest mortality among the dialysis population. We hypothesized that low estrogen status was associated with death in women with ESKD.

METHODS

We measured estradiol and sex hormone levels in female ESKD patients initiating hemodialysis from 2005 to 2012 in four Canadian centers. We divided women into quintiles based on estradiol levels and tested for associations between the estradiol level and cardiovascular (CV), non-CV and all-cause mortality. Participants were further dichotomized by age.

RESULTS

A total of 482 women (60 ± 15 years of age, 53% diabetic, estradiol 116 ± 161 pmol/L) were followed for a mean of 2.9 years, with 237 deaths (31% CV). Estradiol levels were as follows (mean ± standard deviation): Quintile 1: 19.3 ± 0.92 pmol/L; Quintile 2: 34.6 ± 6.6 pmol/L; Quintile 3: 63.8 ± 10.6 pmol/L; Quintile 4: 108.9 ± 19.3; Quintile 5: 355 ± 233 pmol/L. Compared with Quintile 1, women in Quintiles 4 and 5 had significantly higher adjusted all-cause mortality {hazard ratio [HR] 2.12 [95% confidence interval (CI) 1.38-3.25] and 1.92 [1.19-3.10], respectively}. Similarly, compared with Quintile 1, women in Quintile 5 had higher non-CV mortality [HR 2.16 (95% CI 1.18-3.96)]. No associations were observed between estradiol levels and CV mortality. When stratified by age, higher quintiles were associated with greater all-cause mortality (P for trend <0.001) and non-CV mortality (P for trend = 0.02), but not CV mortality in older women.

CONCLUSIONS

In women with ESKD treated with hemodialysis, higher estradiol levels were associated with greater all-cause and non-CV mortality. Further studies are required to determine the mechanism for the observed increased risk.

Estrogen-related mechanisms in sex differences of hypertension and target organ damage

Hypertension (HTN) is a primary risk factor for cardiovascular (CV) events, target organ damage (TOD), premature death and disability worldwide. The pathophysiology of HTN is complex and influenced by many factors including biological sex. Studies show that the prevalence of HTN is higher among adults aged 60 and over, highlighting the increase of HTN after menopause in women. Estrogen (E2) plays an important role in the development of systemic HTN and TOD, exerting several modulatory effects. The influence of E2 leads to alterations in mechanisms regulating the sympathetic nervous system, renin-angiotensin-aldosterone system, body mass, oxidative stress, endothelial function and salt sensitivity; all associated with a crucial inflammatory state and influenced by genetic factors, ultimately resulting in cardiac, vascular and renal damage in HTN. In the present article, we discuss the role of E2 in mechanisms accounting for the development of HTN and TOD in a sex-specific manner. The identification of targets with therapeutic potential would contribute to the development of more efficient treatments according to individual needs.

miR-146b-5p has a sex-specific role in renal and cardiac pathology in a rat model of chronic kidney disease

Chronic kidney disease presents a complex and distinct pathological landscape in men and women, yet this difference is poorly understood. microRNAs are powerful molecular regulators of pathophysiology in the kidney and other organs. We previously reported a significant upregulation of miR-146b-5p in the 5/6 nephrectomy rat model of chronic kidney disease. Here we investigated the sex-specific contribution of miR-146b-5p to renocardiac pathology by generating a novel miR-146b^-/- rat and characterized the expression of miR-146b-5p in both wild-type and knockout animals. The 5/6 nephrectomy or sham surgery was performed on rats of each genotype and sex. Renal pathology was examined through gross histology, plasma and urinary analysis of electrolytes and metabolites, and by chronic blood pressure monitoring. Cardiac pathology was monitored via echocardiography and pressure-volume analysis. The miR-146b^-/- rats show functional knockout of miR-146b-5p in both the kidney and heart. While 5/6 nephrectomy induced tissue hypertrophy, miR-146b^-/- female rats displayed exacerbated renal hypertrophy. Additionally, miR-146b^-/- female rats exhibited a marked elevation of renal fibrosis and significant renal dysfunction yet lower blood pressure and less pronounced cardiac remodeling. These phenotypic differences were not exhibited in miR-146b^-/- male rats. Ovariectomy ameliorated renal pathology and abolished genotypic differences. In vitro examination of transforming growth factor-β signaling in combination with miR-146b-5p manipulation supports a role for miR-146b-5p in mediating the protective benefit of estrogen from renal pathologies. Thus, our data highlight an important role of miR-146b-5p in modulating kidney disease progression and provide new avenues for the study of sex-specific pathology.

Hormone therapy and clinical and surrogate cardiovascular endpoints in women with chronic kidney disease: a systematic review and meta-analysis

OBJECTIVE

Women with chronic kidney disease (CKD) experience kidney dysfunction-mediated premature menopause. The role of postmenopausal hormone therapy (HT) in this population is unclear. We sought to summarize current knowledge regarding use of postmenopausal HT and cardiovascular (CV) outcomes, and established surrogate measures of CV risk in women with CKD.

METHODS

This is a systematic review and meta-analysis of adult women with CKD. We searched electronic bibliographic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) (inception to 2014 December), relevant conference proceedings, tables of contents of journals, and review articles. Randomized controlled trials and observational studies examining postmenopausal HT compared with either placebo or untreated control groups were included. The intervention of interest was postmenopausal HT, and the outcome measures were all-cause and CV mortality, nonfatal CV event (myocardial infarction, stroke), and surrogate measures of CV risk (serum lipids, blood pressure).

RESULTS

Of 12,482 references retrieved, four randomized controlled trials and two cohort studies (N = 1,666 participants) were identified. No studies reported on CV outcomes or mortality. Compared with placebo, postmenopausal HT was associated with decreased low-density lipoprotein cholesterol (-13.2 mg/dL [95% CI, -23.32 to -3.00 mg/dL]), and increased high-density lipoprotein (8.73 mg/dL [95% CI, 4.72-12.73 mg/dL]) and total cholesterol (7.96 mg/dL [95% CI, 0.07-15.84 mg/dL]). No associations were observed between postmenopausal HT triglyceride levels and blood pressure.

CONCLUSIONS

Studies examining the effect of postmenopausal HT on CV outcomes in women with CKD are lacking. Further prospective study of the role of postmenopausal HT in this high-risk group is required.

Changes in fertility and hormone replacement therapy in kidney disease

Infertility is common among men and women with CKD and fertility is usually restored with successful kidney transplantation. There are many causes of infertility in those on dialysis, including sexual dysfunction and impaired spermatogenesis and ovulation resulting from an altered hormonal milieu. There is little information about infertility in CKD, but it is clear that ESRD results in low rates of pregnancy in women. Early reports of increased pregnancy rates in women on nocturnal hemodialysis suggest that this modality may improve the abnormal reproductive hormonal milieu of ESRD; small studies of men on dialysis also suggest this. Just as the specific causes of infertility in men and women with CKD/ESRD are unknown, we also lack information about the appropriateness of hormone replacement in these patients. This paper reviews these linked issues, pointing out the lack of data upon which to base clinical decision-making about these quality-of-life issues in our CKD/ESRD patients.

Adynamic bone in patients with chronic kidney disease

Adynamic bone in patients with chronic kidney disease (CKD) is a clinical concern because of its potential increased risk for fracture and cardiovascular disease (CVD). Prevalence rates for adynamic bone are reportedly increased, although the variance for its prevalence and incidence is large. Differences in its prevalence are largely attributed to classification and population differences, the latter of which constitutes divergent groups of elderly patients having diabetes and other comorbidities that are prone to low bone formation. Most patients have vitamin D deficiency and the active form, 1,25-dihydroxyvitamin D, invariably decreases to very low levels during CKD progression. Fortunately, therapy with vitamin D receptor activators (VDRAs) appears to be useful in preventing bone loss, in part, by its effect to stimulate bone formation and in decreasing CVD morbidity, and should be considered as essential therapy regardless of bone turnover status. Future studies will depend on assessing cardiovascular outcomes to determine whether the risk/reward profile for complications related to VDRA and CKD is tolerable.

Effects of estradiol, calcitriol and both treatments combined on bone histomorphometry in rats with chronic kidney disease and ovariectomy

BACKGROUND

The aim of this experimental study was to analyze the histomorphometric changes observed when using different doses of estradiol, calcitriol and both treatments combined, in rats with both chronic kidney disease (CKD) and ovariectomy (OVX).

METHODS

Six groups of rats with CKD+OVX were treated for 8 weeks with placebo, with different doses of 17beta-estradiol (E2), with calcitriol or with both treatments combined (E2+calcitriol). Histomorphometric studies were carried out at the proximal tibia segment.

RESULTS

All groups that received active treatments showed a trabecular bone volume similar to those of rats with normal ovarian function. Treatment with E2 was effective, E2-10 diminished osteoid and eroded surfaces, and E2-30 was able to achieve a bone remodeling similar to that of the normal group. Calcitriol proved to have a positive effect on bone microarchitecture, achieving normal trabecular connectivity. The combined treatment with E2-30+calcitriol was the most effective treatment as it was not only capable of achieving normal trabecular remodeling and connectivity, but also normal trabecular bone volume.

CONCLUSIONS

E2 and calcitriol seem to have independent effects on cancellous bone turnover in rats with CKD+OVX. In rats with chronic kidney disease and ovariectomy, these two agents are able to produce additive effects on bone and offer additional advantages as opposed to the use of both drugs independently.

HEMATOLOGY: ISSUES IN THE DIALYSIS PATIENT: The Safety of Heparins in End-Stage Renal Disease

In patients on chronic dialysis, unfractionated heparin (UFH) is the most commonly used agent for anticoagulation of the hemodialysis extracorporeal circuit, for hemodialysis catheter "locking" between dialysis treatments, and for nondialysis indications such as venous thromboembolic disease, peripheral vascular disease, and acute coronary artery disease. Potentially serious complications of UFH, such as hemorrhage, osteoporosis, and thrombocytopenia, have led to consideration of other options for anticoagulation, including low molecular weight heparin (LMWH) and direct thrombin inhibitors (DTIs). LMWH can be used for anticoagulation of the hemodialysis circuit, but whether this has significant benefit compared to UFH remains to be proven. Because of the somewhat unpredictable risk of severe bleeding complications when LMWH is used for other indications in dialysis patients, UFH rather than LMWH is preferred for treatment of thromboembolic disease in these patients. DTIs have been used for anticoagulation in dialysis patients with heparin-induced thrombocytopenia (HIT), with argatroban being the preferred agent if heparin-free hemodialysis cannot be performed. UFH still remains the preferred anticoagulant in the vast majority of dialysis patients requiring systemic anticoagulation and for anticoagulation of the extracorporeal hemodialysis circuit.

Effect of tibolone on markers of cardiovascular disease risk in postmenopausal women undergoing hemodialysis: a pilot study

OBJECTIVE

To assess the effect of tibolone on markers of vascular risk in postmenopausal women who were receiving hemodialysis.

DESIGN

One-year open-label study.

SETTING

"Zvezdara" University Medical Center, Belgrade, Serbia.

PATIENT(S)

Twenty-eight postmenopausal women undergoing chronic hemodialysis.

INTERVENTION(S)

Fifteen women received tibolone 2.5 mg three times per week; 13 other women served as controls.

MAIN OUTCOME MEASURE(S)

Mean arterial pressure and weight were measured at baseline and at 6 and 12 months, and blood was collected for insulin, total cholesterol, low-density lipoprotein, high-density lipoprotein, triglycerides, lipoprotein(a), high-sensitivity C-reactive protein (hs-CRP), endothelin-1 (ET-1), vascular endothelial growth factor (VEGF), and markers of renal function.

RESULT(S)

Mean arterial pressure fell in the tibolone but not in the control group at 6 and 12 months versus baseline (mean [SD]: 93 [15] vs. 105 [11] mmHg and 94 [10] vs. 105 [11] mmHg, respectively). Weight, insulin, lipids, lipoprotein(a), hs-CRP, ET-1, VEGF, and renal function remained unchanged within each group, but high-density lipoprotein concentrations fell in the tibolone group after 12 months (1.2 [0.3] vs. 1.6 [0.6] mmol/L).

CONCLUSION(S)

The effects of tibolone on markers of vascular risk in postmenopausal women who are receiving hemodialysis and healthy women appear to differ. This should be taken into account when tailoring menopausal therapies to the specific requirements of each individual.

Pharmacokinetics of oral micronized beta-estradiol in postmenopausal women receiving maintenance hemodialysis

BACKGROUND

Although 11% of postmenopausal women with end-stage renal disease (ESRD) are prescribed hormone replacement therapy (HRT), the appropriate use remains poorly explored. Although there remains controversy surrounding the benefits of HRT, it may be of particular interest in this population, which has a high risk of bone loss and a fourfold increase in fracture risk compared to the general population. However, the appropriate dose of estrogen for use in postmenopausal women with ESRD is not known. The objective of this study was to evaluate the steady-state pharmacokinetics of oral micronized beta-estradiol in postmenopausal women with ESRD compared with postmenopausal women with normal renal function in order to determine equivalent dosing.

METHODS

Six postmenopausal women with ESRD receiving maintenance hemodialysis and 6 healthy postmenopausal controls received 14 days of micronized beta-estradiol (1.0 mg for control, 0.5 mg for ESRD). Blood, urine, and dialysate samples were obtained during a dosage interval on day 14. Estradiol, estrone, albumin, and sex-hormone binding globulin (SHBG) concentrations were determined. Free estradiol concentrations were calculated using a previously described method.

RESULTS

Women with ESRD had significantly lower serum albumin (610 +/- 31 micromol/L vs. 684 +/- 83 micromol/L) and SHBG (78 +/- 17 vs. 118 +/- 13 nmol/L) than control subjects. Total clearance of estradiol was not significantly different. Due to difference in binding, free estradiol concentrations were significant higher in ESRD women (53.2 +/- 17.7 pg/mL) than control women (43.5 +/- 8.7 pg/mL), despite receiving 50% of the dose. There was no significant difference in estrone concentrations. Clearance of both estradiol and estrone in the dialysate was minimal.

CONCLUSION

Women with ESRD should receive approximately 50% of the dose typically prescribed to women without ESRD.

Postmenopausal osteoporosis in the dialysis patient

PURPOSE OF REVIEW

Osteoporosis is the most prevalent bone disorder in the general population, particularly in the middle and older age groups. Although more than half of the prevalent dialysis population is within these age groups, little concern has been given to the possible role of estrogen deficiency in the pathogenesis of bone disease in end-stage renal disease. The purpose of this review is to summarize the recent published evidence that supports a potential role of the postmenopausal state in the pathogenesis of bone disease in end-stage renal disease and their implications for treatment.

RECENT FINDINGS

Recent studies have shown that although the risk factors for fracture in end-stage renal disease are similar to the general population, the incidence is three to fourfold higher. The high prevalence of older population, the frequently observed premature amenorrhea and early menopause in dialysis patients may play a role. Similarly, the proportion of end-stage renal disease women receiving hormone replacement therapy is at least three times lower than the general population. Recent evidence on the risk of hormone replacement therapy should caution about its use in end-stage renal disease patients. New evidence suggests that selective estrogen receptor modulators may increase bone mass without significant secondary effects. Other alternatives, such as the use of bisphosphonates, should be considered with caution due to the risk of excessive suppression of bone turnover, worsening or favoring the development of adynamic bone disease.

SUMMARY

Osteoporosis should be recognized as an important entity that may modify the current conception of renal osteodystrophy in postmenopausal patients with end-stage renal disease. Further clinical studies are needed in order to propose strategies that may reduce the impact of postmenopausal osteoporosis in the dialysis population.

Permanent cessation of menses and postmenopausal hormone use in dialysis-dependent women: the HELP study

BACKGROUND

Earlier onset of menopause is associated with an increased risk for cardiovascular disease, especially among women with surgical menopause. Information on age at or reasons for the permanent cessation of menses among women with end-stage renal disease (ESRD) remains limited, although cardiovascular disease accounts for more than half of all cardiovascular deaths in this population.

METHODS

We used data from the Hemodialysis and Estrogen Levels in Postmenopausal Patients Study to examine the reported age when menses permanently ceased, reasons for the permanent cessation of menses, and prevalence of surgical menopause. We also investigated the frequency of current and past postmenopausal hormone (PMH) use among dialysis-dependent women and their views toward PMH therapy.

RESULTS

Among 238 postmenopausal hemodialysis-dependent women, median age when menses permanently ceased was 48 years. Permanent cessation of menses was attributed to natural causes in 65%, surgical reasons in 30% (16%, hysterectomy without bilateral oophorectomy; 14%, hysterectomy with bilateral oophorectomy), kidney failure in 2%, radiation or chemotherapy in 1%, and other causes in 2%. Among women with a history of bilateral oophorectomy, 71% became menopausal before the age of 35 years. Current and past PMH use was reported by 6% and 17% of the women, respectively, whereas 77% were never administered hormones. Only 2% stated a kidney doctor ever recommended PMH therapy, and 54% said they would not take PMHs if prescribed by their kidney doctor.

CONCLUSION

Many women with ESRD experience surgical menopause before the age of 35 years, which may contribute to the excess cardiovascular mortality among women with ESRD. PMH use remains low among dialysis-dependent women. However, two randomized controlled trials have noted a significantly increased risk for cardiovascular events in women administered estrogen in combination with progestin. Thus, risks associated with PMH use may outweigh the benefits in a population with a very high rate of cardiovascular disease, such as postmenopausal hemodialysis-dependent women.

Atrial fibrillation in chronic dialysis patients in the United States: risk factors for hospitalization and mortality

BACKGROUND

The incidence and risk factors for hospitalized atrial fibrillation have not been previously assessed in a national population of dialysis patients.

METHODS

We analyzed the United States Renal Data System (USRDS) Dialysis Morbidity and Mortality Study (DMMS) Wave II in a historical cohort study of hospitalized atrial fibrillation. Data from 3374 patients who started dialysis in 1996 with valid follow-up times were available for analysis, censored at the time of renal transplantation and followed until November 2000. Cox Regression analysis was used to model factors associated with time to first hospitalization for atrial fibrillation (ICD9 code 427.31x) adjusted for comorbidities, demographic factors, baseline laboratory values, blood pressures, dialysis modality, and cardioprotective medications.

RESULTS

The incidence density of atrial fibrillation was 12.5/1000 person years. Factors associated with atrial fibrillation were older age (> or = 71 years vs. <48 years), extremes (both high and low) of pre-dialysis systolic blood pressure, dialysis modality (hemodialysis vs. peritoneal dialysis), and digoxin use. Baseline use of coumadin was associated with reduced mortality in patients later hospitalized for atrial fibrillation.

CONCLUSIONS

Dialysis patients had a high incidence of atrial fibrillation. This risk was largely segregated among those with established risk factors for atrial fibrillation, and hemodialysis patients. Use of coumadin was associated with improved survival among patients later hospitalized for atrial fibrillation.

Pathophysiology and recent advances in the management of renal osteodystrophy

Bone disease is observed in 75-100% of patients with chronic renal failure as the glomerular filtration rate (GFR) falls below 60 ml/minute. Hyperparathyroid (high turnover) bone disease is found most frequently followed by mixed osteodystrophy, low-turnover bone disease, and osteomalacia. With advancing renal impairment, "skeletal resistance" to parathyroid hormone (PTH) occurs. To maintain bone turnover, intact PTH (iPTH) targets from two to four times the upper normal range have been suggested, but whole PTH(1-84) assays indicate that amino-terminally truncated fragments, which accumulate in end-stage renal disease (ESRD), account for up to one-half of the measured iPTH. PTH levels and bone-specific alkaline phosphatase (BSAP) provide some information on bone involvement but bone biopsy and histomorphometry remains the gold standard. Calcitriol and calcium salts can be used to suppress PTH and improve osteomalacia but there is growing concern that these agents predispose to the development of vascular calcification, cardiovascular morbidity, low-turnover bone disease and fracture. Newer therapeutic options include less calcemic vitamin D analogues, calcimimetics and bisphosphonates for hyperparathyroidism, and sevelamer for phosphate control. Calcitriol and hormone-replacement therapy (HRT) have been shown to maintain bone mineral density (BMD) in certain patients with end-stage renal disease (ESRD). After renal transplantation, renal osteodystrophy generally improves but BMD often worsens. Bisphosphonate therapy may be appropriate for some patients at risk of fracture. When renal bone disease is assessed using a combination of biochemical markers, histology and bone densitometry, early intervention and the careful use of an increasing number of effective therapies can reduce the morbidity associated with this common problem.

Herbs, menopause, and dialysis

Women with chronic kidney disease (CKD) are at increased risk for menstrual disorders, early menopause, and osteoporosis, and rarely discuss gynecologic and reproductive issues with their nephrologist. Various complementary and alternative medicine (CAM) products are of interest to women with end-stage renal disease (ESRD) who have these disorders. However, very little is known about the specifics of using herbal medicines in patients on chronic dialysis, resulting in numerous problems when patients and providers try to ascertain the safety and efficacy of these products. This article reviews evidence regarding the safety and efficacy of black cohosh, ginseng, chastetree, dong quai, evening primrose oil, soy products, and the so-called natural hormones. Pharmacologic parameters important to evaluating the quality of botanical products are discussed, along with recommendations and information resources.

Hormone replacement therapy in postmenopausal women with end-stage renal disease: a review of the issues

Hormone replacement is an integral part of therapies to prevent osteoporosis in postmenopausal women and may be considered a component in the treatment of dyslipidemia, cardiovascular disease, and possibly cognitive function. The indications for, and efficacy and prescription of, hormone replacement therapy in postmenopausal women with ESRD have been infrequently studied and less than 10% of postmenopausal women on dialysis are receiving hormone replacement. Small studies suggest that hormone replacement therapy is valuable in treating the dyslipidemia of women on dialysis, but indicate that a reduction in the dosage of hormone replacement may be needed. A potential role for hormone replacement therapy in the treatment and/or prevention of osteoporosis and sexual dysfunction in postmenopausal women on dialysis exists as well.

Estrogen replacement therapy: implications for postmenopausal women with end-stage renal disease

Little information is available about either the potential beneficial or harmful effects of estrogen replacement therapy in postmenopausal women with end-stage renal disease. Although evidence supports a role for estrogen replacement therapy in postmenopausal women in the prevention of cardiovascular disease and bone loss, possible improvement in cognitive function, and the relief of menopausal symptoms, these conclusions may not be applicable to patients with end-stage renal disease, since these studies have generally excluded such women. This issue is of considerable importance since cardiovascular causes account for more than 50% of the all-cause mortality in patients with end-stage renal disease. However, estrogen replacement therapy may also have untoward effects in patients with the disease, including an increased risk of dialysis access thrombosis and potentially worsening coronary artery disease in postmenopausal patients. Furthermore, dosing of estrogens needs to be done carefully since renal excretion is important for the elimination of estrogen metabolites. Low dose or alternate day dosing in addition to monitoring estrogen levels may be warranted when prescribing estrogen replacement therapy to women with end-stage renal disease. In this review, it is our objective to analyze the evidence published in the literature so far and to weigh the risks and benefits of estrogen therapy in postmenopausal women with end-stage renal disease.