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Abstract

Background:

Hispanic/Latino individuals are less likely to receive optimal treatment for chronic kidney disease than non-Hispanic whites. This may be particularly detrimental for women of reproductive age as chronic kidney disease increases risk for infertility, menstrual irregularities, and pregnancy loss. While these maternal outcomes have been associated with advanced chronic kidney disease, their occurrence in early chronic kidney disease is unclear.

Objectives/Design:

Using baseline (2008–2011) and second study visit (2014–2017) data from the Hispanic Community Health Study/Study of Latinos, we retrospectively assessed the prevalence of chronic kidney disease as well as the association between chronic kidney disease and self-reported infertility, cessation of menses, hysterectomy, and nonviable pregnancy loss (experienced at less than 24 weeks gestation) in women of reproductive age (18–45 years).

Methods:

Multivariable survey logistic regression analyses determined the unadjusted and multivariable-adjusted prevalence odds ratios with 95% confidence intervals between chronic kidney disease and the separate outcomes.

Results:

Among 2589 Hispanic/Latino women included (mean age = 31.4 years), 4.6% were considered to have chronic kidney disease. In adjusted analyses, women with chronic kidney disease did not have a significantly increased odds of infertility (odds ratio = 1.02, 95% confidence interval = 0.42–2.49), cessation of menses (odds ratio = 1.25, 95% confidence interval = 0.52–3.04), or hysterectomy (odds ratio = 1.17, 95% confidence interval = 0.61–2.25) compared to those without chronic kidney disease. In those with chronic kidney disease, the adjusted odds of a nonviable pregnancy loss occurring after baseline visit were increased (odds ratio = 2.11, 95% confidence interval = 0.63–7.02) but not statistically significance.

Conclusion:

The presence of early stage chronic kidney disease did not confer a significant risk of infertility, cessation of menses, or nonviable pregnancy loss.

Plain language summary

The Hispanic Community Health Study/Study of Latinos is a population-based study of over 16,000 Hispanic/Latino individuals throughout the United States. Within this cohort, we assessed the prevalence of chronic kidney disease in women of reproductive age (18–45 years old) and the associations between kidney disease and infertility, cessation of menses, and nonviable pregnancy loss (loss occurring before the 24th week of pregnancy). We found that kidney disease affected 1 in 20 women of reproductive age and those with kidney disease were more likely to have obesity, diabetes, and hypertension. Compared to those without kidney disease, the presence of kidney disease did not increase risk of infertility, cessation of menses, or nonviable pregnancy loss.

Keywords

chronic kidney disease Hispanic/Latino infertility pregnancy loss

Introduction

Impaired fertility, menstrual irregularities, and early menopause have been described in women with chronic kidney disease (CKD) including those on dialysis.^1
–5 These conditions are thought to be related to uremic toxins and an altered gonadal axis, resulting in hyperprolactinemia and a reduced cyclic surge of luteinizing and follicle stimulating hormones.^6
–10 Women receiving dialysis appear to have higher rates of early pregnancy loss.¹¹ While this may in part be related to higher rates of comorbid conditions such as obesity,¹² diabetes,¹³ and hypertension,¹⁴ a uremic milieu likely also plays a role.¹⁵ While these conditions have been associated with advanced CKD, the prevalence of impaired fertility, cessation of menses, and early pregnancy loss in women with early CKD, which affects a higher percentage of women of reproductive age, has not been well described.

Hispanic/Latinos in the United States are less likely to be screened for kidney disease risk factors or receive optimal treatment for CKD after diagnosis.^16,17 They have a nearly 40% higher prevalence of requiring dialysis than non-Hispanic whites and may experience increased risk of disease progression.^18,19 In the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a prospective study of over 16,000 individuals throughout the United States, the prevalence of CKD in all women (aged 18–74 years) was 13% and disease unawareness for men and women combined reached 18%.²⁰ Disease unawareness and lack of treatment could be particularly detrimental for Hispanic/Latino women of reproductive age as minority women are disproportionately affected by the rising rates of early pregnancy loss.^21,22 This has significant clinical implications as early pregnancy loss has also been associated with anxiety/depression, post-traumatic stress disorder, and increased risk for future chronic disease.^23,24

To assess the impact of CKD on fertility, menstrual irregularities, and early pregnancy loss in Hispanic/Latinos in the United States, we performed a secondary analysis of data from the HCHS/SOL baseline (2008–2011) and second study visit (2014–2017). We assessed the prevalence of CKD in Hispanic/Latino women of reproductive age (18–45 years old) as well as the separate associations between CKD and infertility, cessation of menses, hysterectomy (as a marker for abnormal uterine bleeding), and nonviable pregnancy loss (occurring at less than 24 weeks gestation).

Materials and methods

Study population

The HCHS/SOL is a population-based cohort of adult Hispanic/Latinos from 9872 randomly selected households in four field communities (Bronx, New York; Chicago, Illinois; Miami, Florida; and San Diego, California) to assess the role of acculturation in the prevalence and development of disease and to identify factors playing a protective or harmful role in the health of Hispanics/Latinos. The sample design and cohort selection have been previously described.^25,26 Briefly, a stratified two-stage area probability sample of household addresses was selected in each community. The first sampling stage randomly selected census block groups with stratification based on Hispanic/Latino concentration and proportion of high/low socioeconomic status. The second sampling stage randomly selected households, with stratification, from United States Postal Service registries that covered the randomly selected census block groups. Sampling weights were generated to reflect the probabilities of selection at each stage.

At the baseline visit (2008–2011), 4119 women were in the reproductive age range and 2810 women returned for a second study visit between 2014 and 2017. Women were included in the present analysis if they were 18–45 years old at the baseline visit, provided serum and/or urine samples at both visits (for CKD determination; 210 excluded due to lack of specimens) and completed the reproductive and medical history questionnaires (11 additionally excluded due to incomplete questionnaires) with final n = 2589. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were followed when preparing this article.

CKD may affect up to 6% of pregnancies²⁷ and infertility affects up to 1 in 6 people worldwide.²⁸ With a two-group χ² test with a 0.050 two-sided significance level, we estimated we would have 80% power to detect a difference in subfertility between those with CKD (6% of population and outcome risk of 18%) and those without CKD (94% of population and outcome risk 10%) (odds ratio (OR) of 1.98) when sample sizes are 154 and 2411, respectively (a total sample size of 2565).

Data collection

Each study visit included clinical measurements, fasting venous blood collection, and spot urine specimens. Participants were asked to bring all current medications to each visit. Questionnaires were used to obtain information on demographic factors, acculturation, medical, and social history. At the second visit, all women were asked to complete a reproductive and medical history questionnaire and a pregnancy complication questionnaire. The information obtained from these questionnaires included pregnancy events occurring both before and after the baseline visit (see Supplemental material).

Exposure assessment

Serum creatinine, urine albumin, and estimated glomerular filtration rate (eGFR, calculated using the Chronic Kidney Disease Epidemiology Collaboration equation)²⁹ were obtained from the study data. Given our younger cohort, we utilized an expanded definition of CKD to include if a participant had the following: (1) eGFR < 60 mL/min per 1.73 m² at one visit and <70 mL/min per 1.73 m² at another, (2) urine albumin to creatinine ratio (UACR) >300 mg/g (considered severely increased albuminuria) at either visit, and (3) UACR >30 mg/g at baseline visit while taking an angiotensin-converting enzyme-inhibitor or angiotensin receptor blocker and was <30 mg/g at the subsequent visit. Our primary analysis utilized this CKD definition. A sensitivity analysis was also performed and restricted to a more conventional CKD definition, defined by having one of the following on two occasions (i.e. at both study visits): eGFR < 60 mL/min per 1.73 m² or a UACR of >30 mg/g on spot urine sample.

Outcome assessment

The reproductive and pregnancy questionnaires were developed by a committee of content and methodologic experts, with questions derived from previously validated questionnaires and piloted within the community of participants. In the reproductive questionnaire, infertility was assessed with the question, “Have you ever tried to become pregnant for greater than one year without success?” and women were also asked to report the perceived cause of their infertility (medical problem in themselves, their partner, or both). Cessation of menses was assessed with “Have your natural periods stopped permanently?” as well as the reason why it occurred. All women were asked to report a history of hysterectomy. Women reported their total number of pregnancies and how many occurred before or after the baseline visit. Early pregnancy losses occurring before the baseline visit were specified (miscarriage vs tubal/ectopic vs other) but were combined as pregnancies lasting less than 24 weeks when occurring after baseline visit.

Covariates

Covariates from the baseline visit included age, body mass index (BMI), hypertension, and diabetes. Hypertension was defined as a sitting systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or use of an antihypertensive medication (documented or self-reported use of an antihypertensive medication). Diabetes mellitus was defined as fasting plasma glucose of ≥126 mg/dL, 2-h post-load glucose levels of ≥200 mg/dL, a hemoglobin A1c level of ≥6.5%, or self-reported diabetes.

Statistical analyses

Summary statistics, prevalence estimates, and ORs were weighted to adjust for sampling probability and nonresponse.^25,26 All analyses account for cluster sampling and the use of stratification in sample selection. Survey-specific procedures were used in all analyses to account for the two-stage sampling design, stratification, and clustering. Descriptive statistics including mean ± standard deviation and counts and percentages were employed to characterize differences among women with CKD versus those without. Bivariate analysis included chi-square tests for categorical variables and adjusted Wald tests for continuous variables. We used survey logistic regression analyses to determine the unadjusted and multivariable-adjusted associations between CKD and the separate outcomes of infertility, cessation of menses, hysterectomy, and nonviable pregnancy loss.

Due to the limited number of outcome events, we assessed the influence of potential confounders (participant’s age, BMI, presence of diabetes, and hypertension at baseline study visit) one at a time to ensure model convergence. For each study outcome, we used backward elimination with a 10% change in estimate approach for final covariate selection. Prevalence ORs and their 95% confidence intervals (95% CIs) were computed. All statistical tests were two-sided with a significance level of 0.05. Analyses were performed using Stata software (version 15.1; StataCorp LLC, College Station, TX, USA).

Results

Study cohort characteristics

A total of 2589 women met study selection criteria and were included in the analysis. Table 1 displays the characteristics of the study cohort at the baseline study visit, both overall and stratified by CKD status. At baseline visit, the mean age was 31.4 ± 8.3 years, and most (n = 1146, 44.3%) identified their heritage/ethnicity as Mexican, followed by Cuban (n = 375, 14.5%) and Puerto Rican (n = 329, 12.7%). According to our study definition, 120 (4.6%) were classified as having CKD. Compared to those without CKD, women with CKD were older (35.1 vs 31.2 years old), had a higher BMI (33.4 kg/m² vs 29.3 kg/m²), had over three times the prevalence of diabetes (25.5% vs 7.0%) and over four times the prevalence of hypertension (30.7% vs 6.7%) compared to those without CKD. The average time between baseline and second study visit was 6.2 years. The majority (n = 81, 67.5%) of women met criteria for CKD due to a persistently elevated UACR at both visits; the median (interquartile range) UACR of those with CKD at the second visit was 123.8 (36.4–493.9) mg/g compared to 4.1 (2.5–7.9) mg/g in those without CKD.

Table 1.

HCHS/SOL baseline visit (2008–2011) characteristics of all reproductive age women and by CKD status.

Characteristic	Overall (n = 2589)	Without CKD (n = 2469)	With CKD (n = 120)
Age* (years)	31.4 ± 8.3	31.2 ± 8.3	35.1 ± 7.7
BMI* (kg/m²)	29.5 ± 7.1	29.3 ± 7.1	33.4 ± 7.4
Heritage/ethnicity (%)
Central American	8.1	7.9	12.6
Cuban	14.5	14.7	9
Dominican	11.4	11.4	10.5
Mexican	44.3	44.1	47.3
Puerto Rican	12.7	12.6	14.6
South American	4.3	4.5	1
More than one	4.7	4.7	5
High school diploma or more (%)	72.8	73.1	65.7
Cigarette use (past or current) (%)	23.3	23.3	22.1
Alcohol use (past or current) (%)	77.6	77.8	74.3
Diabetes* (%)	7.8	7.0	25.5
Hypertension* (%)	7.8	6.7	30.7
Average systolic BP (mm Hg)	108.5 ± 12.4	108.2 ± 12.0	115.9 ± 18.3
Average diastolic BP (mm Hg)	68.6 ± 10.1	68.3 ± 9.8	74.8 ± 14.1
ACE-I/ARB, baseline visit* (%)	3.5	2.7	20.2
Creatinine (mg/dL)	0.70 ± 0.1	0.70 ± 0.1	0.76 ± 0.3
Estimated GFR* (mL/min/1.73 m²)	111.7 ± 16.2	112.0 ± 15.7	104.2 ± 24.7
Urine albumin-to-creatinine ratio* (mg/g)	6.7 (4.8–11.3)	6.5 (4.7–10.5)	77.6 (42.1–284.7)

HCHS/SOL: Hispanic Community Health Study, Study of Latinos; CKD: chronic kidney disease; BMI: body mass index; BP: blood pressure; ACE-I/ARB: angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker; GFR: glomerular filtration rate.

Data are mean ± standard deviation or percent except for urine albumin-to-creatinine ratio which is median (interquartile range).

Statistically significant (p < 0.05) difference between women without CKD and women with CKD.

CKD and infertility, cessation of menses, and hysterectomy

Infertility was reported by 15.0% of women with CKD and 12.8% of women without CKD. Of those who responded to a question of the perceived cause of infertility (n = 142), no woman with CKD reported the cause was due to their partner while 7.5% of women without CKD reported their infertility was due to their partner. Cessation of menses was reported by 26.7% of women with CKD and 14.5% of women without CKD at similar mean (41.3 vs 41.8) and median (44 (37–47) vs 44 (39–47)) ages. Reasons cited for amenorrhea included “They stopped naturally” (44.3% with CKD vs 48.3% without CKD), “Surgery to remove ovaries or uterus” (26.0% with CKD vs 38.9% without CKD), and “Other” (29.6% with CKD vs 10.5% without CKD). A history of hysterectomy was reported by 7.1% of women with CKD and 6.1% without CKD.

Table 2 compares the prevalence ORs for self-reported infertility, cessation of menses, and hysterectomy in women with versus without CKD. Compared to women without CKD, those with CKD did not have a significantly increased odds of infertility (adjusted OR = 1.02, 95% CI = 0.42–2.49). In a crude comparison, women with CKD had twice the odds of experiencing cessation of menses (OR = 2.15, 95% CI = 1.15–4.0), but this was attenuated and no longer significant after adjustment for age and BMI (OR = 1.25, 95% CI = 0.52–3.04). The odds of hysterectomy were not statistically different between women with versus without CKD (OR = 1.17, 95% CI = 0.61–2.25); an adjusted analysis was not performed due to the low number of events. In the sensitivity analyses (n = 96), prevalence ORs were higher for infertility, cessation of menses, and hysterectomy in women with CKD, but the estimates were not substantially different from the primary analysis (Table 2).

Table 2.

Multivariable adjusted association between CKD and self-reported infertility, cessation of menses, and hysterectomy among reproductive age women in the HCHS/SOL.

Characteristic	n	Infertility		Cessation of Menses		Hysterectomy
Characteristic	n	UnadjustedOR (95% CI)	Adjusted^a OR (95% CI)	UnadjustedOR (95% CI)	Adjusted^b OR (95% CI)	UnadjustedOR (95% CI)	AdjustedOR (95% CI)
Primary analyses
No CKD	2469	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
CKD	120	1.20 (0.49–2.95)	1.02 (0.42–2.49)	2.15 (1.15–4.00)	1.25 (0.52–3.04)	1.17 (0.61–2.25)	NA
Sensitivity analyses^c
No CKD	2493	Ref.	Ref.	Ref.	Ref.	Ref.	Ref.
CKD	96	1.41 (0.54–3.69)	1.19 (0.46–3.10)	2.66 (1.36–5.20)	1.74 (0.66–4.61)	1.35 (0.66–2.77)	NA

CKD: chronic kidney disease; HCHS/SOL: Hispanic Community Health Study, Study of Latinos; OR: odds ratio; CI: confidence interval; Ref.: referent; NA: not applicable.

Adjusted OR for hysterectomy not performed due to a low number of events.

Adjusted for BMI.

Adjusted for age and BMI.

In the sensitivity analysis, CKD was defined as either a low eGFR (<60 mL/min per 1.73 m²) or a urine albumin-to-creatinine ratio of >30 mg/g on spot urine samples at both visits.

CKD and pregnancy loss

A majority of women (92.9% with CKD and 85.4% without CKD) reported a history of pregnancy and almost half (42.3% of women with CKD and 46.1% without CKD) reported a history of at least one nonviable loss. As shown in Table 3, the presence of CKD was not associated with an increased risk of a nonviable pregnancy loss (adjusted OR = 0.89, 95% CI = 0.53–1.48). A sensitivity analysis using the restricted CKD definition showed similar results (Table 3). In addition, we repeated our analyses excluding those with GFR <60 mL/min per 1.73 m² at either visit and noted similar results (data not shown).

Table 3.

Association between CKD and nonviable pregnancy loss among reproductive age women in the HCHS/SOL.

Characteristic	Nonviable loss among women with history of pregnancy at any time (n = 2277)		Nonviable loss among women reporting pregnancy after baseline visit (n = 630)
Characteristic	UnadjustedOR (95% CI)	Adjusted^a OR (95% CI)	UnadjustedOR (95% CI)	Adjusted^b OR (95% CI)
Primary analyses
No CKD	Ref.	Ref.	Ref.	Ref.
CKD	0.86 (0.52–1.43)	0.89 (0.53–1.48)	1.81 (0.56–5.90)	2.11 (0.63–7.02)
Sensitivity analyses^c
No CKD	Ref.	Ref.	Ref.	Ref.
CKD	0.88 (0.49–1.60)	0.91 (0.50–1.66)	1.66 (0.43–6.36)	1.80 (0.48–6.81)

CKD: chronic kidney disease; HCHS/SOL: Hispanic Community Health Study, Study of Latinos; OR: odds ratio; CI: confidence interval; Ref.: referent.

Adjusted for BMI.

Adjusted for diabetes.

In the sensitivity analysis, CKD was defined as either a low GFR (<60 mL/min per 1.73 m²) or a urine albumin-to-creatinine ratio of >30 mg/g on spot urine samples at both visits.

Discussion

With a focus on Hispanic/Latino women throughout the United States, our study builds upon prior literature evaluating the impact of CKD on women’s reproductive health. As the percent of Hispanic/Latino women of reproductive age with CKD is largely unknown, our findings were reassuringly similar to prior literature that has estimated CKD to affect 6% of all reproductive age women.²⁷ Infertility is a rising global public health issue that can lead to significant psychological distress.³⁰ Taking into account comorbidities known to also be associated with menstrual irregularities and infertility,^31,32 our study provides support that early stage CKD may not be associated with increased risk. This may be reassuring to young patients newly diagnosed with early CKD and to providers engaged in shared-decision, family planning discussions with these individuals. As women in the United States continue to delay childbearing, including those of Hispanic/Latino origin,³³ interventions focused on slowing CKD progression could hopefully lower risk of future infertility.

Previous research has demonstrated that dysfunctional uterine bleeding, menorrhagia, and amenorrhea are common in women with advanced CKD.^4,7,34 Assessing early menopause is clinically prudent as it is associated with both ischemic cardiovascular disease and increased mortality.³⁵ In a population of post-menopausal women, data from the Women’s Health Initiative found women with CKD were more likely to have had menopause before age 45 years (26% vs 23%, p = 0.02) although there was no difference in prevalence of hysterectomy in women with CKD versus without CKD (1.2% vs 2.0%, p = 0.16).³⁶ While the overall small number of events limited our statistical power in reproductive age women, this could be further assessed in future studies examining all adult women enrolled in HCHS/SOL.

Spontaneous abortion, or miscarriage, is the most common complication in early pregnancy, and the incidence in clinically recognized pregnancies is between 8% and 20%.^37,38 Well-known risk factors include maternal age over 35 years old, previous spontaneous abortion, and maternal smoking, although minority women may also be at higher risk for miscarriage.²² Our study seemed to suggest this as well, with 45.9% of parous women reporting at least one nonviable loss. The rates of nonviable pregnancy loss in women with CKD are not well described. In those with advanced CKD or requiring dialysis, the blood urea nitrogen level is inversely related to the length of gestation.³⁹ For those with early CKD, it is unclear if other mechanisms, such as endothelial dysfunction, increase risk of early loss.⁴⁰ Although women who receive a kidney transplant can often see a rapid return of fertility, reported miscarriage rates range between 15.4% and 45% in this population.^41
–43 In the general population, elevated preconception maternal blood pressure has been found to increase the risk of miscarriage.¹⁴ Although 30.7% of our CKD cohort were considered to have hypertension, it did not emerge as a strong confounder in our final model when assessing risk for nonviable pregnancy loss.

There are several limitations to our study that merit consideration. In our reproductive age participants from the HCHS/SOL, CKD (by our expanded definition) was present in only 4.6%, which ultimately limited the power of our analyses. As this study was secondary analysis of existing data, we were limited from performing a priori sample size calculations and were restricted to the exposures and outcomes captured during the HCHS/SOL observational cohort study. As CKD is a progressive condition, and childbearing continues to be delayed among all races/ethnicities in the United States,³³ it is possible that both the percentage with CKD and the number of pregnancies has increased since the completion of the second study visit. Future work could reassess our study outcomes as the cohort matures and additional data are available from subsequent study visits. Our CKD definition was outside the conventional clinical definition but was felt to be justified for a younger population and included severely increased albuminuria, a known risk marker for CKD progression.^44
–46 Although we were able to utilize measurements over 6 years apart to verify the diagnosis of CKD, the initial onset of CKD was unknown. Likewise, specific dates of pregnancy were not provided and only reported as before or after baseline visit. Therefore, only prevalence ORs could be performed. This may help account for the higher ORs of nonviable pregnancy loss in women with CKD when examining only pregnancies that occurred after baseline visit (although this was imprecise given our small numbers). Finally, the women’s health and reproductive outcomes were gathered at the second study visit, and were self-reported, thus subject to recall bias. While infertility was assessed in all women by asking whether they had “ever tried to become pregnant for greater than one year without success,” current guidelines recognize this interval should be shortened to 6 months for women older than 35 years old.⁴⁷ Menopause was assessed clinically by cessation of menses but was not confirmed with biochemical evidence and did not consider those menstruating with anovulatory cycles, known to occur in CKD. Given the paucity of data among individuals with chronic disease, as future population health studies are developed, consideration should be given to prioritize capture of reproductive health outcomes in these targeted groups.

Women with CKD desire more information related to the risks of pregnancy loss and the potential impact of their CKD on their ability to conceive.⁴⁸ Our data may better inform family planning discussions and the complex shared decisions surrounding reproductive health between patients and their providers. Overall, optimization of comorbidities including hypertension and diabetes, along with attempting to conceive in earlier stages of CKD, may aid in both achieving conception and avoiding pregnancy loss. Likewise, evaluating for underlying CKD in Hispanic/Latino women who experience nonviable pregnancy loss may also be justified. Larger prospective studies of women with all stages of CKD attempting to conceive are warranted.

Conclusion

In this large Hispanic/Latino cohort throughout the United States, the presence of CKD, largely represented by early stage CKD, did not confer a significant risk of infertility, cessation of menses, or nonviable pregnancy loss.

Supplemental Material

sj-docx-1-whe-10.1177_17455057231224544 – Supplemental material for Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos

Supplemental material, sj-docx-1-whe-10.1177_17455057231224544 for Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos by Monica L Reynolds, Laura R Loehr, Susan L Hogan, Yichun Hu, Carmen R Isasi, Christina Cordero, Ana C Ricardo, James P Lash and Vimal K Derebail in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057231224544 – Supplemental material for Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos

Supplemental material, sj-docx-2-whe-10.1177_17455057231224544 for Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos by Monica L Reynolds, Laura R Loehr, Susan L Hogan, Yichun Hu, Carmen R Isasi, Christina Cordero, Ana C Ricardo, James P Lash and Vimal K Derebail in Women’s Health

Supplemental Material

sj-docx-3-whe-10.1177_17455057231224544 – Supplemental material for Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos

Supplemental material, sj-docx-3-whe-10.1177_17455057231224544 for Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos by Monica L Reynolds, Laura R Loehr, Susan L Hogan, Yichun Hu, Carmen R Isasi, Christina Cordero, Ana C Ricardo, James P Lash and Vimal K Derebail in Women’s Health

Footnotes

Acknowledgements

The authors thank the HCHS/SOL staff and participants for their important contributions. A complete list of staff and investigators is available on the study website http://www.cscc.unc.edu/hchs/. Preprint: Monica Reynolds, Laura R Loehr, Susan L Hogan et al. Infertility and Pregnancy Loss in Hispanic/Latino Women with Chronic Kidney Disease: Results from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), 14 December 2020, PREPRINT (Version 2) available at Research Square ().

Declarations

ORCID iD

Monica L Reynolds

Supplemental material

Supplemental material for this article is available online.

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