Authors' Reply: Gestational Diabetes as a Window into Underdocumented CKD in Women

We thank Dong and Shi for their thoughtful and insightful letter1 regarding our recent JASN publication, “Clinical Implications of Missed CKD Diagnosis in Adults with and without Diabetes Mellitus,”2 on the basis of the nationwide Israeli Clalit Health Services cohort. Their comments highlight an important and clinically relevant perspective on the potential role of gestational diabetes mellitus in identifying women at higher risk for unrecognized CKD. We agree that pregnancy-related dysglycemia may represent a valuable opportunity for early risk stratification and timely intervention. We appreciate the authors' emphasis on the life-course implications of gestational diabetes mellitus for kidney health and its potential role in improving early CKD detection. Unfortunately, within the framework of our current database, we do not have reliable or systematic documentation of gestational diabetes diagnoses. Consequently, we are unable to accurately identify women with prior gestational diabetes mellitus and therefore cannot assess the prevalence of undocumented CKD in this specific subgroup. Our study relied on routinely collected electronic health record data spanning more than two decades. During much of this period, pregnancy-related diagnoses and obstetric history were not consistently captured in structured formats within the health system. As a result, retrospective identification of gestational diabetes mellitus with sufficient accuracy is not feasible, and additional analyses addressing this important question cannot be reliably performed using the existing dataset. Nevertheless, we share the authors' interest in better understanding disparities in CKD recognition. Building on our findings from the Clalit cohort, we are currently planning further analyses focusing on population groups in which we observed particularly high rates of under-documentation, including women, Arab populations, and Orthodox Jewish communities. These studies aim to further elucidate clinical, cultural, and health system factors that may contribute to delayed or missed CKD diagnosis. We fully agree that postpartum follow-up after gestational diabetes mellitus represents an important opportunity to improve long-term kidney and cardiometabolic outcomes. Future studies incorporating dedicated obstetric, metabolic, and longitudinal kidney data will be essential to more comprehensively evaluate the role of gestational diabetes mellitus in CKD recognition and prevention. We thank Dong and Shi for their valuable contribution and for advancing the discussion on improving early identification of CKD in vulnerable populations.