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Abstract
Sexual dysfunction is defined as any abnormality in sexual arousal, libido, intercourse, orgasm, or satisfaction. It is prevalent in patients with chronic and end-stage kidney disease, with 70% to 84% of men and 30% to 60% of women reporting some form of sexual dysfunction. Although kidney transplantation improves the overall quality of life for patients receiving dialysis, it can have unexpected effects on sexual function owing to the use of immunosuppressive medications and comorbid illnesses. It is important to recognize these adverse effects and pre-emptively discuss them with patients to help mitigate consequent psychosocial discontent. Women of reproductive age will often recover fertility after kidney transplantation and therefore need to be empowered to prevent unwanted pregnancies and plan for a safe pregnancy if desired. Complications such as preeclampsia, pregnancy-induced hypertension, gestational diabetes, ectopic pregnancy, still birth, low birth weight, and preterm birth are more common in pregnant women with a kidney transplant. Careful monitoring for infection, rejection, and immunosuppressive dose adjustment along with comanagement by a high-risk obstetrician is of utmost importance. Breast-feeding is safe with most immunosuppressive medications and should be encouraged.
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Oliverio AL, Bramham K, Hladunewich MA. Pregnancy and CKD: Advances in Care and the Legacy of Dr Susan Hou. Am J Kidney Dis 2021; 78:865-875. [PMID: 34656369 DOI: 10.1053/j.ajkd.2021.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/13/2021] [Indexed: 11/11/2022]
Abstract
Dr Susan Hou began her illustrious nephrology career at a time when pregnancy in women with chronic kidney disease (CKD) was hazardous and actively discouraged. Her pioneering research in women's health provided much of the early outcome data that shaped our current understanding of CKD and pregnancy. Although many uncertainties regarding optimal management of this vulnerable patient group remain, recent decades have witnessed important advances and renewed interest in improving care for pregnant women with CKD. Many nephrologists have been inspired by Dr Hou's lifetime of work and are grateful for her generous collaborations. In this In Practice Review, we honor her legacy by providing an update of current literature and clinical management guidance in the context of a clinical case vignette that challenges us to consider the many complex aspects to the counseling and care of women with CKD who desire a pregnancy.
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Affiliation(s)
- Andrea L Oliverio
- Department of Internal Medicine, Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Kate Bramham
- Department of Women and Children's Health, King's College London, London, United Kingdom; Department of Renal Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Michelle A Hladunewich
- Divisions of Nephrology and Obstetrics, Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada.
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53
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Iltis AS, Mehta M, Sawinski D. Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease. HEC Forum 2021:10.1007/s10730-021-09463-7. [PMID: 34617168 DOI: 10.1007/s10730-021-09463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.
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Affiliation(s)
- Ana S Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA.
| | - Maya Mehta
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA
| | - Deirdre Sawinski
- Renal Electrolyte, and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Dines VA, Garovic VD, Parashuram S, Cosio FG, Kattah AG. Pregnancy, Contraception, and Menopause in Advanced Chronic Kidney Disease and Kidney Transplant. WOMEN'S HEALTH REPORTS 2021; 2:488-496. [PMID: 34841395 PMCID: PMC8617582 DOI: 10.1089/whr.2021.0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 12/05/2022]
Abstract
Background: Reproductive health is an essential part of the care of women with kidney disease. However, the self-reported patient experience of reproductive issues has been underexplored. Materials and Methods: We identified a cohort of women ages 18 to 44 at the time of kidney transplant from 1996 to 2014 at our 3-site program (n = 816). We sent each woman a survey on her reproductive lifespan, characterizing features from menarche to menopause. Results: We received survey responses from 190 patients (27%). One third of respondents reported amenorrhea before transplant, and 61.5% of these women reported resumption of menses post-transplant. The average age of menopause was 45.5 years, earlier than the general population (51.3 years). There were 204 pregnancies pretransplant and 52 pregnancies post-transplant. Pregnancies post-transplant were more likely to be complicated by preeclampsia, preterm delivery, and small for gestational age babies than pregnancies that occurred >5 years before transplant. Pregnancies <5 years before transplant were similar to post-transplant pregnancies with respect to complications. Forty-two percent of women were advised to avoid pregnancy after transplant, most often by a nephrology provider. Conclusions: In our cohort of kidney transplant recipients, women report increased pregnancy-related complications post-transplant and in the 5 years before transplant, compared with pregnancies that occurred greater than 5 years before transplant. They were often counseled to avoid pregnancy altogether. Women reported a younger age of menopause relative to the general population. This should be considered when counseling patients with chronic kidney disease regarding optimal pregnancy timing.
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Affiliation(s)
- Virginia A. Dines
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Vesna D. Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Santosh Parashuram
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernando G. Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrea G. Kattah
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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Yin O, Kallapur A, Coscia L, Kwan L, Tandel M, Constantinescu SA, Moritz MJ, Afshar Y. Mode of Obstetric Delivery in Kidney and Liver Transplant Recipients and Associated Maternal, Neonatal, and Graft Morbidity During 5 Decades of Clinical Practice. JAMA Netw Open 2021; 4:e2127378. [PMID: 34605918 PMCID: PMC8491100 DOI: 10.1001/jamanetworkopen.2021.27378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/22/2021] [Indexed: 12/23/2022] Open
Abstract
Importance Rates of cesarean delivery (CD) are increased among transplant recipients. There is a need to define the indications for CD and associated outcomes among transplant recipients to determine the safest mode of obstetric delivery. Objective To evaluate the association of mode of obstetrical delivery with maternal and neonatal morbidity among pregnant women who have received a kidney or liver transplant. Design, Setting, and Participants This registry-based retrospective cohort study used data from the Transplant Pregnancy Registry International, which has recruited participants since 1991 from 289 diverse academic and community settings, mainly in North America. Eligible participants were recipients of a kidney or liver transplant who were aged 18 years or older at the time of a live birth at or later than 20 weeks' gestational age and who delivered between 1968 and 2019. The data were analyzed from April 30, 2020, to April 16, 2021. Exposures Scheduled CD, a trial of labor resulting in CD (TOL-CD), or a TOL resulting in vaginal delivery (TOL-VD). Main Outcomes and Measures The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariate regression was conducted to calculate odds ratios (ORs) or β values and 95% CIs with adjustment for differences in maternal comorbidities and gestational age at delivery. Nonmedical indications for CD are those not associated with decreased morbidity or mortality in the obstetric literature. Results This study included 1865 women, of whom 1435 were kidney transplant recipients and 430 were liver transplant recipients. The age range of the participants was 18 to 48 years; the median body mass index among the participants was in the normal range, and the median transplant-to-conception interval was more than 2 years. Compared with a scheduled CD, a TOL was not associated with increased severe maternal morbidity among kidney transplant recipients (TOL-CD: adjusted odds ratio [aOR], 1.80 [95% CI, 0.77-4.22]; TOL-VD: aOR, 1.22 [95% CI, 0.57-2.62]) (for liver transplant recipients, the numbers were too small for multivariate modeling). In the adjusted model, a TOL was associated with a decrease in neonatal composite morbidity among kidney transplant recipients who underwent TOL-CD (aOR, 0.52; 95% CI, 0.32-0.82) and TOL-VD (aOR, 0.36; 95% CI, 0.24-0.53) and liver transplant recipients who underwent TOL-VD (aOR, 0.41; 95% CI, 0.19-0.87) but not for TOL-CD (aOR, 0.58; 95% CI, 0.21-1.61). The main factors associated with CD after labor were placental abruption (aOR, 12.96; 95% CI, 2.85-59.07) and pregestational diabetes (aOR 5.44; 95% CI, 2.54-11.68). The rate of CD was 51.6% (741 of 1435) among kidney transplant recipients and 41.4% (178 of 430) among liver transplant recipients. In total, 229 of 459 kidney transplant recipients (49.9%) and 50 of 105 liver transplant recipients (47.6%) had scheduled CDs performed for either a nonmedical indication or a repeated indication, although women with these indications are candidates for a TOL. Conclusions and Relevance In this cohort study, TOL vs a scheduled CD was associated with improved neonatal outcomes among kidney and transplant recipients and not with increased severe maternal morbidity among kidney transplant recipients. These findings may be used to facilitate multidisciplinary decisions regarding the mode of obstetrical delivery.
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Affiliation(s)
- Ophelia Yin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles
| | - Aneesh Kallapur
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Lorna Kwan
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles
| | - Megha Tandel
- Department of Urology, David Geffen School of Medicine, University of California, Los Angeles
| | - Serb an Constantinescu
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
- Section of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Michael J. Moritz
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
- Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania
- Department of Surgery, Morsani College of Medicine, Tampa, Florida
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles
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Ponticelli C, Zaina B, Moroni G. Planned Pregnancy in Kidney Transplantation. A Calculated Risk. J Pers Med 2021; 11:jpm11100956. [PMID: 34683097 PMCID: PMC8537874 DOI: 10.3390/jpm11100956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022] Open
Abstract
Pregnancy is not contraindicated in kidney transplant women but entails risks of maternal and fetal complications. Three main conditions can influence the outcome of pregnancy in transplant women: preconception counseling, maternal medical management, and correct use of drugs to prevent fetal toxicity. Preconception counseling is needed to prevent the risks of an unplanned untimely pregnancy. Pregnancy should be planned ≥2 years after transplantation. The candidate for pregnancy should have normal blood pressure, stable serum creatinine <1.5 mg/dL, and proteinuria <500 mg/24 h. Maternal medical management is critical for early detection and treatment of complications such as hypertension, preeclampsia, thrombotic microangiopathy, graft dysfunction, gestational diabetes, and infection. These adverse outcomes are strongly related to the degree of kidney dysfunction. A major issue is represented by the potential fetotoxicity of drugs. Moderate doses of glucocorticoids, azathioprine, and mTOR inhibitors are relatively safe. Calcineurin inhibitors (CNIs) are not associated with teratogenicity but may increase the risk of low birth weight. Rituximab and eculizumab should be used in pregnancy only if the benefits outweigh the risk for the fetus. Renin-angiotensin system inhibitors, mycophenolate, bortezomib, and cyclophosphamide can lead to fetal toxicity and should not be prescribed to pregnant women.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Barbara Zaina
- Department of Obstetrics and Gynecology, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gabriella Moroni
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, 20122 Milan, Italy;
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57
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van Buren MC, Beck DK, Lely AT, van de Wetering J, Massey EK. EXPloring attitudes and factors influencing reproductive Choices in kidney Transplant patients (The EXPECT-study). Clin Transplant 2021; 35:e14473. [PMID: 34453355 PMCID: PMC9285546 DOI: 10.1111/ctr.14473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 11/29/2022]
Abstract
Pregnancy can have risks after kidney transplantation (KT). This mixed‐methods study aimed to identify the percentage of women getting pregnant after KT and explore motives for and against pregnancy together with psychosocial and medical factors involved in decision making. Furthermore, experiences of pregnancy and child‐raising were explored. Women who got pregnant after KT were matched with women who had not been pregnant after KT. Semi‐structured interviews were conducted, transcribed verbatim and analyzed using directed content analysis. After KT, only 12% of women got pregnant. Eight women with pregnancies after KT were included (P‐group) and matched with 12 women who had not been pregnant after KT (NP‐group). Women after KT experienced a high threshold to discuss their pregnancy wish with their nephrologist. The nephrologists’ advice played an important role in decision‐making, but differed between the groups. In the P‐group, a desire for autonomy and positive role models were decisive factors in proceeding with their pregnancy wish. In the NP‐group, disease burden and risk perception were decisive factors in not proceeding with their pregnancy. Nephrologists need to be proactive in broaching this subject and aware of factors influencing the decision and outcomes. Standardized preconception guidelines on pregnancy counseling are recommended.
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Affiliation(s)
- Marleen C van Buren
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center, Rotterdam, The Netherlands
| | - Denise K Beck
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center, Rotterdam, The Netherlands
| | - A Titia Lely
- Department of Obstetrics, Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacqueline van de Wetering
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center, Rotterdam, The Netherlands
| | - Emma K Massey
- Erasmus MC Transplant Institute, Department of Internal Medicine, University Medical Center, Rotterdam, The Netherlands
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58
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Gouveia IF, Silva JR, Santos C, Carvalho C. Maternal and fetal outcomes of pregnancy in chronic kidney disease: diagnostic challenges, surveillance and treatment throughout the spectrum of kidney disease. ACTA ACUST UNITED AC 2021; 43:88-102. [PMID: 33460427 PMCID: PMC8061969 DOI: 10.1590/2175-8239-jbn-2020-0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/31/2020] [Indexed: 01/01/2023]
Abstract
Pregnancy requires several physiological adaptations from the maternal organism, including modifications in the glomerular filtration rate and renal excretion of several products. Chronic kidney disease (CKD) can negatively affect these modifications and consequently is associated with several adverse maternal and fetal adverse outcomes (gestational hypertension, progression of renal disease, pre-eclampsia, fetal growth restriction, and preterm delivery). A multidisciplinary vigilance of these pregnancies is essential in order to avoid and/or control the harmful effects associated with this pathology. Dialysis and transplantation can decrease the risks of maternal and fetal complications, nonetheless, the rates of complications remain high comparing with a normal pregnancy. Several recent developments in this area have improved quality and efficacy of treatment of pregnant women with CKD. This article summarizes the most recent literature about CKD and pregnancy.
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Affiliation(s)
- Inês Filipe Gouveia
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Joana Raquel Silva
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Clara Santos
- Serviço de Nefrologia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Claudina Carvalho
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
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Punjala SR, Phillips BL, Chowdhury P, Pile T, Karydis N, Kessaris N, Olsburgh J, Harding K, Callaghan CJ, Nelson-Piercy C, Drage M. Outcomes of pregnancy in simultaneous pancreas and kidney transplant recipients: A single-center retrospective study. Clin Transplant 2021; 35:e14435. [PMID: 34292634 DOI: 10.1111/ctr.14435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 11/28/2022]
Abstract
Simultaneous pancreas and kidney (SPK) transplantation, in uremic women with insulin-dependent diabetes, increases the chance of a successful pregnancy and minimizes the risk to infants. The aim of this study was to document pregnancy and explore the challenges in this cohort of women. Retrospective analysis of women who underwent pancreas transplantation between January 1, 1998 and 8 January, 2019 was conducted. Seventeen pregnancies were identified in 13 women. Mean transplant-to-pregnancy interval was 4.6 years (range, 1.1-10.2 years). Eleven pregnancies resulted in live birth (65%), and six (35%) ended in miscarriage/fetal loss at a median gestational age of 8.5 weeks. Mean gestational age at delivery was 34.9 weeks (SD ±3 weeks). Preeclampsia and C-section rates were 77% and 67%, respectively. Adverse fetal and graft outcomes were observed in 100% of unplanned pregnancies, compared to 10% of planned pregnancies (P < .001). One kidney allograft was lost during pregnancy; one pancreas and two kidney allografts were lost within 3 years of pregnancy. This is a high-risk group for grafts and offspring. Pre-pregnancy planning is vital. A multidisciplinary approach by obstetric and transplant teams is important pre-pregnancy, antenatally, and peripartum. This is the largest published series of pregnancies in SPK recipients from a single center.
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Affiliation(s)
- Sai Rithin Punjala
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Benedict Lyle Phillips
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paramit Chowdhury
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Taryn Pile
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nikolaos Karydis
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicos Kessaris
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathon Olsburgh
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kate Harding
- Women's Services Directorate, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Martin Drage
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
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60
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Kallapur A, Jang C, Yin O, Mei JY, Afshar Y. Pregnancy care in solid organ transplant recipients. Int J Gynaecol Obstet 2021; 157:502-513. [PMID: 34245162 DOI: 10.1002/ijgo.13819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022]
Abstract
Recipients of solid organ transplants who become pregnant represent an obstetrically high-risk population. Preconception planning and effective contraception tailored to the individual patient are critical in this group. Planned pregnancies improve both maternal and neonatal outcomes and provide a window of opportunity to mitigate risk and improve lifelong health. Optimal management of these pregnancies is not well defined. Common pregnancy complications after transplantation include hypertension, preterm birth, infection, and metabolic disease. Multidisciplinary preconception and prepartum management, and counseling decrease complications and benefit the maternal-neonatal dyad.
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Affiliation(s)
- Aneesh Kallapur
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Christine Jang
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Ophelia Yin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Jenny Y Mei
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Abstract
Chronic liver disease in pregnancy is rare. Historically, many chronic liver diseases were considered contraindications to pregnancy; however, with current monitoring and treatment strategies, pregnancy may be considered in many cases. Preconception and initial antepartum consultation should focus on disease activity, medication safety, risks of pregnancy, as well as the need for additional monitoring during pregnancy. In most cases, a multidisciplinary approach is necessary to ensure optimal maternal and fetal outcomes. Despite improving outcomes, pregnancy in women with the chronic liver disease remains high risk.
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Turgut E, İnan G, Günaydın DB, Büyükgebiz B, Konca S, Karçaaltıncaba D, Bayram M. Antenatal follow-up, anesthesia management and perinatal outcomes in pregnancy with renal transplant. Turk J Obstet Gynecol 2021; 18:109-114. [PMID: 34083610 PMCID: PMC8191322 DOI: 10.4274/tjod.galenos.2021.37336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: Due to the recent increase in the successful pregnancies after renal transplant, the number of renal transplant recipients having vaginal or cesarean delivery possibly associated with high maternal, fetal and/or neonatal risk requiring team approach increased. We aimed to evaluate antenatal follow-up, perinatal outcomes, and anesthesia management in pregnancies with renal transplantation and to compare them with the current literature. Materials and Methods: After ethics committee approval, renal transplant recipients who gave birth in our hospital between January 2010 and December 2019 were documented in this retrospective study. Demographic characteristics, comorbidities, antenatal follow-up, anesthesia management, and maternal, fetal, and neonatal outcomes were presented. Results: A total of 20 pregnant women who underwent renal transplant were identified. The mean age of the parturients was 31±5 years. The median interval from transplantation to conception was 8.15±4.8 years. Antenatal mean serum creatinine level and proteinuria were 1.48±1.39 mg/dL and 1.397±1.316 mg/dL, respectively. No allograft rejection was recorded. Comorbidities including hypertension (n=12), preeclampsia (n=6), and preterm delivery (n=10) were noted. The median gestational age was 35±3 weeks and the median newborn weight was 2.520±832 gram. There was one abortion, two pregnancy terminations, and 17 deliveries (3 vaginal and 14 cesareans). Cesarean sections (11/14; 78.6%) were mostly performed under spinal block and general anesthesia was performed in three (21.4%) women. Epidural analgesia for vaginal delivery was recorded in one parturient. Conclusion: Despite the presence of preterm delivery and comorbidities, antenatal/peripartum follow-up and analgesia/anesthesia management of renal transplant recipients revealed good perinatal outcomes.
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Affiliation(s)
- Ezgi Turgut
- Gazi University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Gözde İnan
- Gazi University Faculty of Medicine, Department of Anesthesiology, Ankara, Turkey
| | - Dudu Berrin Günaydın
- Gazi University Faculty of Medicine, Department of Anesthesiology, Ankara, Turkey
| | - Beyza Büyükgebiz
- Gazi University Faculty of Medicine, Department of Anesthesiology, Ankara, Turkey
| | - Sibel Konca
- Gazi University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Deniz Karçaaltıncaba
- Gazi University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
| | - Merih Bayram
- Gazi University Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara, Turkey
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63
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Pregnancy and Lung Transplantation. CURRENT PULMONOLOGY REPORTS 2021. [DOI: 10.1007/s13665-021-00274-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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64
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DeFilippis EM, Haythe JH, Walsh MN, Kittleson MM. Intersection of Heart Failure and Pregnancy: Beyond Peripartum Cardiomyopathy. Circ Heart Fail 2021; 14:e008223. [PMID: 33980039 DOI: 10.1161/circheartfailure.120.008223] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Heart failure (HF) is a leading cause of morbidity and mortality in pregnant women in the United States. Although peripartum cardiomyopathy is the most common diagnosis for pregnant women with HF, women with preexisting cardiomyopathies and systolic dysfunction are also at risk as the hemodynamic demands of pregnancy can lead to decompensation, arrhythmia, and rarely death. The differential diagnosis of HF in pregnancy is broad and includes Takotsubo or stress cardiomyopathy, exacerbation of a preexisting cardiomyopathy, such as familial cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, or left ventricular noncompaction. This review will explore the implications of pregnancy in women with preexisting cardiomyopathies and de novo HF, risk assessment and preconception planning, decisions about contraception, the safety of HF medications and implantable cardioverter-defibrillators during pregnancy, pregnancy in women with left ventricular assist devices and following heart transplantation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | - Jennifer H Haythe
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | | | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
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65
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Hewawasam E, Davies CE, Gulyani A, Li Z, Clayton PA, Sullivan E, McDonald SP, Jesudason S. Factors influencing fertility rates in Australian women receiving kidney replacement therapy: Analysis of linked ANZDATA registry and perinatal data over 22 years. Nephrol Dial Transplant 2021; 37:1152-1161. [PMID: 33848341 DOI: 10.1093/ndt/gfab157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pregnancy in women receiving kidney replacement therapy (KRT) is uncommon, and trends and factors influencing fertility rates remain poorly defined. METHODS The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) was linked to mandatory perinatal datasets (all births from 1991-2013, ≥20 weeks' gestation) in four Australian jurisdictions. Overall, age and era-specific fertility rates were calculated based on general and KRT population denominators. RESULTS From 2,948,084 births, 248 babies were born to 168 mothers receiving KRT (37 babies born to 31 dialysed mothers; 211 babies born to 137 transplanted mothers). Substantial agreement between ANZDATA and perinatal datasets was observed for birth events and outcomes. Transplanted women had higher fertility rates than dialysed women in all analyses, with 21.4 live births/1000 women/year (95% CI: 18.6-24.6) in transplanted women, 5.8 (95% CI: 4.1-8.1) in dialysed women and 61.9 (95% CI: 61.8-62.0) in the Non-KRT cohort. Fertility rates for dialysed women rose in recent years. After adjusting for maternal age and treatment modality, Caucasian women had higher fertility rates, while women with pre-existing diabetes, or transplanted women with exposure to KRT for ≤3.0 years had lower rates. As expected, transplanted women with a pre-conception estimated glomerular filtration rate (eGFR) of < 45 or transplant-to-pregnancy interval of < 1.0 year had lower fertility rates. Geographical location, socioeconomic status and primary disease (glomerulonephritis vs. other) did not affect fertility rates. CONCLUSIONS Reporting of births to ANZDATA is sufficiently accurate to justify ongoing data collection. Rising fertility rates in dialysed women may indicate permissive attitudes towards pregnancy. Treatment modality, ethnicity, diabetes, pre-conception eGFR, transplant-to-pregnancy interval and duration of KRT exposure were associated with fertility rates. These factors should be considered when counselling women with kidney disease about parenthood.
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Affiliation(s)
- Erandi Hewawasam
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South, Australia
| | - Christopher E Davies
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South, Australia
| | - Aarti Gulyani
- School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South, Australia
| | - Zhuoyang Li
- Faculty of Health and Medicine, University of Newcastle, New South Wales
| | - Philip A Clayton
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South, Australia.,Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, South, Australia
| | - Elizabeth Sullivan
- Faculty of Health and Medicine, University of Newcastle, New South Wales
| | - Stephen P McDonald
- Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, South Australian Health & Medical Research Institute (SAHMRI), Adelaide, South, Australia.,Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South, Australia.,Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, South, Australia
| | - Shilpanjali Jesudason
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South, Australia.,Central Northern Adelaide Renal and Transplantation Services (CNARTS), Royal Adelaide Hospital, Adelaide, South, Australia
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66
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Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2020010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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67
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Boulay H, Mazaud-Guittot S, Supervielle J, Chemouny JM, Dardier V, Lacroix A, Dion L, Vigneau C. Maternal, foetal and child consequences of immunosuppressive drugs during pregnancy in women with organ transplant: a review. Clin Kidney J 2021; 14:1871-1878. [PMID: 34345409 PMCID: PMC8323135 DOI: 10.1093/ckj/sfab049] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/01/2021] [Indexed: 02/06/2023] Open
Abstract
Although pregnancy remains exceptional in women after heart, liver or lung transplant, obstetricians and nephrologists are regularly confronted with pregnancy in renal transplant recipients. National and international registries have described the epidemiology of maternal, foetal and neonatal complications, and transplantation societies have published recommendations on the monitoring of these high-risk pregnancies. In this review, we summarize the existing data on maternal and foetal complications of pregnancies in women after renal transplant, especially the management of immunosuppression. We also describe the few available data on the middle- and long-term outcomes of their children who were exposed in utero to immunosuppressive drugs.
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Affiliation(s)
- Hugoline Boulay
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Séverine Mazaud-Guittot
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Jeanne Supervielle
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Jonathan M Chemouny
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Virginie Dardier
- Laboratoire de psychologie, comportement, cognition et communication (LP3 C), Université Rennes-Rennes 2, Rennes, France
| | - Agnes Lacroix
- Laboratoire de psychologie, comportement, cognition et communication (LP3 C), Université Rennes-Rennes 2, Rennes, France
| | - Ludivine Dion
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Cécile Vigneau
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
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68
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Egerup P, Carlson N, Bruun Oestergaard L, Blanche P, Scott JR, Hornum M, Torp-Pedersen C, Christiansen OB. Increased risk of neonatal complications and infections in children of kidney-transplanted women: A nationwide controlled cohort study. Am J Transplant 2021; 21:1171-1178. [PMID: 32786135 DOI: 10.1111/ajt.16259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 01/25/2023]
Abstract
Information related to short- and long-term risks of children born to kidney-transplanted women remains limited. With the aim of investigating the risk of neonatal complications, and the short- and long-term risk of infections in offspring of kidney-transplanted women, all children born to kidney-transplanted women in Denmark from 1964 to 2016 were identified in a nationwide retrospective matched cohort study. A total of 124 children of kidney-transplanted women were identified and matched on gender, birth year, and number of siblings at birth 1:10 with children born to nontransplanted women identified in the Danish general population. Prevalence of low birth weight (37.9%, risk ratio [RR] = 12.61; 95% confidence interval [CI], 8.5-18.5), premature birth (46.0%, RR = 11.32; 95% CI, 8.1-15.7) and malformations (11.3%, RR = 1.98; 95% CI, 1.2-3.4) was increased in children of kidney-transplanted women compared with controls. Similarly, prevalence of hospitalization due to infection was increased during the first year of life (21.0%, RR = 1.94; 95% CI, 1.3-2.8), from age 1 to 5 (34.2%, RR = 1.89; 95% CI, 1.4-2.5), and overall (41.9%, RR = 1.67; 95% CI, 1.3-2.1). The risk of infection was also higher in children of kidney-transplanted mothers born preterm or with low birth weight compared with similar controls. In conclusion, risk of neonatal complications, malformations, and both early and late infection were increased in children born to kidney-transplanted women.
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Affiliation(s)
- Pia Egerup
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Obstetrics and Gynaecology, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark.,The Research Department, The Danish Heart Foundation, Copenhagen, Denmark
| | | | - Paul Blanche
- Department of Cardiology, Herlev-Gentofte Hospital, Hellerup, Denmark.,Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - James R Scott
- Department of Obstetrics and Gynaecology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Ole Bjarne Christiansen
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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69
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Sarkar M, Brady CW, Fleckenstein J, Forde KA, Khungar V, Molleston JP, Afshar Y, Terrault NA. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:318-365. [PMID: 32946672 DOI: 10.1002/hep.31559] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Monika Sarkar
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Jean P Molleston
- Indiana University and Riley Hospital for Children, Indianapolis, IN
| | - Yalda Afshar
- University of California, Los Angeles, Los Angeles, CA
| | - Norah A Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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70
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Abstract
BACKGROUND Pregnancy after kidney transplantation is an uncommon event. In addition to the risk to the child and the mother, pregnancy has a certain risk for the transplanted kidney. METHODS We made a retrospective analysis of pregnancy and kidney function over a 49-year period in women with transplanted kidneys monitored at the National Transplant Centre, University Medical Centre Ljubljana, Ljubljana, Slovenia. RESULTS We analyzed 22 pregnancies in 18 women (26-39 years old) 78 ± 37 months after transplantation. Serum creatinine before conception was 92 ± 26 μmol/L; 3 years after delivery, it was 117 ± 67 μmol/L. There were no rejections during pregnancy. Three rejections occurred in the first 9 months after delivery. The median duration of pregnancies was 37 weeks. Preeclampsia occurred in 4 women and severe eclampsia occurred in 2 women. In 19 cases, delivery was by caesarean section. One child was born with trisomy of chromosome 21 and 3 children were born with minor congenital anomalies. CONCLUSIONS Renal function and proteinuria did not deteriorate 3 years after pregnancy, even after 2 pregnancies. Rejections in the early post-pregnancy period were common. Preeclampsia was more frequent than in the average population. The incidence of major congenital anomalies was comparable to that seen in pregnant women without immunosuppression.
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71
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Ziogas IA, Hayat MH, Tsoulfas G. Obstetrical and gynecologic challenges in the liver transplant patient. World J Transplant 2020; 10:320-329. [PMID: 33312893 PMCID: PMC7708880 DOI: 10.5500/wjt.v10.i11.320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
An increasing number of childbearing agewomen undergo liver transplantation (LT) in the United States. Transplantation in this patient subgroup poses a significant challenge regarding the plans for future fertility, particularly in terms of immunosuppression and optimal timing of conception. Intrapartum LT is only rarely performed as the outcome is commonly dismal for the mother or more commonly the fetus. On the other hand, the outcomes of pregnancy in LT recipients are favorable, and children born to LT recipients are relatively healthy. Counseling on pregnancy should start before LT and continue after LT up until pregnancy, while all pregnant LT recipients must be managed by amultidisciplinary team, including both an obstetrician and a transplant hepatologist. Additionally, an interval of at least 1-2 years after successful LT is recommended before considering pregnancy. Pregnancy-induced hypertension, pre-eclampsia, and gestational diabetes mellitus are reported more commonly during the pregnancies of LT recipients than in the pregnancies of non-transplant patients. As adverse fetal outcomes, such asmiscarriage, abortion, stillbirth, or ectopic pregnancy, may occur more often than in the non-transplant population, early planning or delivery either through a planned induction of labor or cesarean section is critical to minimize the risk of complications. No significant long-term physical or phycological abnormalities have been reported in children born to LT recipients.
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Affiliation(s)
- Ioannis A Ziogas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Muhammad H Hayat
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Georgios Tsoulfas
- Department of Surgery, Papageorgiou University Hospital, Aristotle University of Thessaloniki, Thessaloniki 54622, Greece
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72
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Boyer A, Lobbedez T, Ouethrani M, Thuillier Lecouf A, Bouvier N, Châtelet V, Hurault de Ligny B. Paternity in male kidney transplant recipients: a French national survey, the PATeRNAL study. BMC Nephrol 2020; 21:483. [PMID: 33198659 PMCID: PMC7667842 DOI: 10.1186/s12882-020-02115-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/20/2020] [Indexed: 12/11/2022] Open
Abstract
Background There is concern about the impact of immunosuppressive agents taken by male kidney transplant (KT) recipients on the risk of foetal malformations. The aim of our survey was to estimate the paternity rate and the outcomes of pregnancies fathered by kidney transplanted males. Methods This survey analysed 1332 male KT recipients older than 18 years, followed in 13 centres in France. A self-reported questionnaire was used to collect data on the patients, treatments at the time of conception and the pregnancy outcomes. Results The study included data on 349 children from 404 pregnancies fathered by 232 male KT recipients. The paternity rate was 17% (95% CI [15–20]). There were 37 (9%, 95% CI [7–12]) spontaneous abortions, 12 (3%, 95% CI [2–5]) therapeutic abortions, 2 (0.5%, 95% CI [0.1–1]) still births, and 13 (4%, 95% CI [2–6]) malformations reported. Compared to the general population, there was no difference in the proportion of congenital malformations nor unwanted outcomes whether the father was exposed or not to immunosuppressive agents. Conclusions This survey does not provide any warning signal that pregnancies fathered by male patients exposed to immunosuppressive agents, notably the debated MMF/MPA, have more complications than pregnancies in the general population. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12882-020-02115-x.
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Affiliation(s)
- Annabel Boyer
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France. .,U1086 INSERME - ANTICIPE, Centre Régional de Lutte contre le Cancer, François Baclesse, 14076, Caen, Cedex 5, France.
| | - Thierry Lobbedez
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France.,U1086 INSERME - ANTICIPE, Centre Régional de Lutte contre le Cancer, François Baclesse, 14076, Caen, Cedex 5, France.,Unicaen, UFR de Médecine, Normandie Université, 2 rue des Rochambelles, 14032, Caen, Cedex, France
| | - Mohamed Ouethrani
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France
| | - Angélique Thuillier Lecouf
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France
| | - Nicolas Bouvier
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France.,Unicaen, UFR de Médecine, Normandie Université, 2 rue des Rochambelles, 14032, Caen, Cedex, France
| | - Valérie Châtelet
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France.,U1086 INSERME - ANTICIPE, Centre Régional de Lutte contre le Cancer, François Baclesse, 14076, Caen, Cedex 5, France.,Unicaen, UFR de Médecine, Normandie Université, 2 rue des Rochambelles, 14032, Caen, Cedex, France
| | - Bruno Hurault de Ligny
- Centre Universitaire des Maladies Rénales, CHU de Caen, Avenue de la côte de Nacre, 14033, Caen, Cedex 9, France.,Unicaen, UFR de Médecine, Normandie Université, 2 rue des Rochambelles, 14032, Caen, Cedex, France
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73
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Boyle S, Sung-Him Mew T, Lust K, McKenzie S, Javorsky G, Parsonage W. Pregnancy Following Heart Transplantation: A Single Centre Case Series and Review of the Literature. Heart Lung Circ 2020; 30:144-153. [PMID: 33162367 DOI: 10.1016/j.hlc.2020.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 10/03/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Maternal and fetal outcomes of pregnancy amongst cardiac transplant recipients are limited in the current literature. METHODS We describe five pregnancies in three cardiac transplant recipients managed between a tertiary centre for obstetric medicine and an associated state-wide transplant centre between 2014-2018, and provide a narrative review of the literature. RESULTS Pre-conception counselling was undertaken. There were no recent rejection episodes and all women demonstrated good baseline cardiac function. Median maternal age was 27 years (range 23-38 yrs.). Median time from transplantation to pregnancy was 5 years (range 2-14 yrs.). All women were managed with modified immunosuppressant regimens and multidisciplinary care. Cardiac function, tacrolimus levels and renal function were closely monitored with frequent monitoring for common complications of pregnancy. There were no maternal or fetal deaths. There was no evidence of graft rejection and no deterioration in cardiac function. Tacrolimus doses were increased to maintain therapeutic targets. Gestational diabetes occurred in three women and cholestasis of pregnancy occurred in one. Each infant was delivered by vaginal delivery. One mother had postpartum haemorrhage in both pregnancies. Pre-eclampsia did not occur. Median gestation at delivery was 37 weeks (range 35+4-40+5 days) with two preterm deliveries. One (1) infant was born with low birth weight. One (1) infant had jaundice requiring phototherapy. All infants were breastfed. CONCLUSION Pregnancy in transplant recipients confers risk to the mother and fetus. Pre-conception counselling, immunosuppressant tailoring and regular monitoring are paramount to avoid rejection and possible teratogenic complications. Favourable pregnancy outcomes are achievable with specialist multidisciplinary care.
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Affiliation(s)
- Siobhan Boyle
- Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Thomas Sung-Him Mew
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia; Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Karin Lust
- Women's and Newborn's Service, Royal Brisbane and Women's Hospital, Herston, Qld, Australia; Department of Medicine, University of Queensland, Qld, Australia
| | - Scott McKenzie
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - George Javorsky
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Qld, Australia
| | - William Parsonage
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Qld, Australia.
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74
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Davis-Kankanamge C, Higgins J, Allsworth JE, Strickland J. Menstruation and contraception patterns of female adolescent transplant recipients. Pediatr Transplant 2020; 24:e13817. [PMID: 32808738 DOI: 10.1111/petr.13817] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND There is a lack of knowledge regarding menstrual cycles and contraception usage for adolescent transplant patients and families. Solid organ transplant patients start teratogenic medications which have pregnancy implications. We explore adolescent female solid organ transplant recipient and guardian's contraceptive knowledge and attitudes as well as menstrual patterns. METHODS A cross-sectional descriptive research design was utilized to collect information from adolescent female transplant patients who are on mycophenolate mofetil after solid organ transplant and their guardians within our freestanding children's hospital via a survey. The sample consisted of all female adolescent patients who have completed a solid organ transplant and are on mycophenolate mofetil from April 2016 through May 2017. RESULTS Twenty-one patients were approached, of which nineteen patients and seventeen guardians completed the survey. The average age of the patient was 16.2 years. The average age at time of transplant was 12.2 years. The type of transplants includes renal (57.1%), heart (23.8%), and liver (4.8%). There were six patients (33.3%) who had a history of sexual activity; among these patients, the mean number of partners in the last year was 1.2. Menstrual concerns included dysmenorrhea, irregular bleeding, and heavy bleeding pre- and post-transplant, respectively. Participants reported contraceptive counseling prior to and after transplant approximately half of the time. CONCLUSIONS Adolescent solid organ transplant patients have multiple reproductive needs including contraception, dysmenorrhea, and irregular bleeding. Integration of contraceptive knowledge into clinical care received by adolescents with solid organ transplants is supported by knowledge gained through this study.
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Affiliation(s)
| | - Jeanette Higgins
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Jenifer E Allsworth
- Department of Biomedical and Health Informatics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Julie Strickland
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO, USA
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75
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Oliverio AL, Hladunewich MA. End-Stage Kidney Disease and Dialysis in Pregnancy. Adv Chronic Kidney Dis 2020; 27:477-485. [PMID: 33328064 DOI: 10.1053/j.ackd.2020.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 06/01/2020] [Accepted: 06/01/2020] [Indexed: 12/20/2022]
Abstract
End-stage kidney disease is associated with low fertility, with rates of conception in women on dialysis estimated at 1/100th of the general population. However, live birth rates are increasing over time in women on hemodialysis, whereas they remain lower and static in women on peritoneal dialysis. Intensification of hemodialysis, targeting a serum blood urea nitrogen <35 mg/dL or 36 hours of dialysis per week in women with no residual kidney function, is associated with improved live birth rates and longer gestational age. Even in intensively dialyzed cohorts, rates of prematurity and need for neonatal intensive care are high, upwards of 50%. Although women on peritoneal dialysis in pregnancy do not appear to be at increased risk of delivering preterm compared with those on hemodialysis, their infants are more likely to be small for gestational age. As such, hemodialysis has emerged as the preferred dialysis modality in pregnancy. Provision of specialized nephrology, obstetric, and neonatal care is necessary to manage these complex pregnancies and family planning counseling should be offered to all women with end-stage kidney disease.
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76
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Sachdeva M. Contraception in Kidney Disease. Adv Chronic Kidney Dis 2020; 27:499-505. [PMID: 33328066 DOI: 10.1053/j.ackd.2020.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/04/2020] [Accepted: 05/06/2020] [Indexed: 02/02/2023]
Abstract
Unplanned pregnancies account for a large number of encountered pregnancies. One of the reasons for this is the lack of counseling surrounding contraception and subsequently lack of contraception use. A conversation during a regular CKD office visit of simply asking a woman what her plans are regarding pregnancy can lead to further discussion on timing of pregnancy and contraception and eventually safer outcomes for both the mother and fetus. Individual preference, as well as comorbid conditions, should be taken into account when deciding on optimal contraceptive methods. One must remember that contraception counseling and initiation of contraception should not be wrapped up in a single office visit, and there must be continued follow-up to ensure that the woman is using the contraceptive method correctly to prevent any future unplanned pregnancy.
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77
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Gonzalez Suarez ML, Parker AS, Cheungpasitporn W. Pregnancy in Kidney Transplant Recipients. Adv Chronic Kidney Dis 2020; 27:486-498. [PMID: 33328065 DOI: 10.1053/j.ackd.2020.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 11/11/2022]
Abstract
Women with end-stage kidney disease commonly have difficulty conceiving through spontaneous pregnancy, and many suffer from infertility. Kidney transplantation restores the impairment in fertility and increases the possibility of pregnancy. In addition, the number of female kidney transplant recipients of reproductive age has been increasing. Thus, preconception counseling, contraceptive management, and family planning are of great importance in the routine care of this population. Pregnancy in kidney transplant recipients is complicated by underlying maternal comorbidities, kidney allograft function, the effect of pregnancy on the transplanted kidney, and the effect of the maternal health on the fetus, in addition to immunosuppressive medications and their potential teratogenesis. Given the potential maternal and fetal risks, and possible complications during pregnancy, pretransplant and prepregnancy counseling for women of reproductive age are crucial, including delivery of information regarding contraception and timing for pregnancy, fertility and pregnancy rates, the risk of immunosuppression on the fetus, the risk of kidney allograft, and other maternal complications. In this article, we discuss aspects related to pregnancy among kidney transplant recipients and their management.
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78
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Ritchie J, Seidman D, Srisengfa Y, Perito ER, Sarkar M. Family Planning in Liver Transplant: Patient and Provider Knowledge and Practices. Liver Transpl 2020; 26:1233-1240. [PMID: 32583555 DOI: 10.1002/lt.25835] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/06/2020] [Accepted: 05/13/2020] [Indexed: 12/31/2022]
Abstract
Fertility is often impaired in adolescents and women with cirrhosis, but it is rapidly restored after liver transplantation (LT). Early and unplanned pregnancies confer increased risks to maternal, fetal, and graft health, underscoring the need for reproductive counseling. However, data on reproductive practices or counseling in the LT setting are limited. An anonymous online Qualtrics (Provo, UT) survey was sent to transplant patients and providers to gauge knowledge and practices surrounding contraception and pregnancy. Eligible participants included transplant patients aged 14-45 years and their transplant providers. Patient response was 50.0% (74/148), 14 of whom were pre-LT patients and 60 of whom were post-LT patients. Counseling occurred in 37% of patients prior to transplant and 82% after transplant. Most patients (86%) considered family planning a high priority in their transplant care. Contraception- and pregnancy-specific counseling was provided by LT providers in 60% and 44% of patients, respectively. The most desired mode of counseling by patients was in-person discussion with an LT provider (89%). Despite most post-LT patients receiving counseling, only 41% used contraception during the first year after LT, of whom 32% relied on high failure methods. Of the 31/43 (72.1%) provider responses, 96% voiced interest in additional reproductive education. Most providers (90%) correctly advised that patients delay pregnancy during the first year after LT, although misconceptions about safety of estrogen and intrauterine devices were selected by 53% and 42%, respectively. Some favored resources by providers were educational pamphlets in clinic (88%) and automated note templates to prompt family planning inquiry (72%). Transplant patients and providers have key deficiencies in their knowledge of contraception and corresponding practices. Most post-LT patients receive counseling, yet contraception practices are inadequate for preventing unplanned pregnancy. Discussion with transplant providers was the most favored counseling modality by patients, underscoring our critical role in optimizing post-LT reproductive care.
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Affiliation(s)
- Julia Ritchie
- Department of Obstetrics and Gynecology, Saint Luke's University, Bethlehem, PA
| | - Dominika Seidman
- Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, CA
| | - Yanin Srisengfa
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - Emily R Perito
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, San Francisco, CA
| | - Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
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79
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Caretto A, Caldara R, Castiglioni MT, Scavini M, Secchi A. Pregnancy after pancreas-kidney transplantation. J Nephrol 2020; 33:1009-1018. [DOI: 10.1007/s40620-020-00860-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 09/07/2020] [Indexed: 01/06/2023]
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80
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The Authors' Reply: Placental Pathology in Pregnancies After Kidney Transplantation. Transplantation 2020; 104:e216. [PMID: 32569005 DOI: 10.1097/tp.0000000000003120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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81
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Defilippis EM, Kittleson MM. Pregnancy after Heart Transplantation. J Card Fail 2020; 27:176-184. [PMID: 32771397 DOI: 10.1016/j.cardfail.2020.07.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/04/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022]
Abstract
As post-transplant survival improves, many heart transplant (HT) recipients are of, or are surviving to, childbearing age. Solid-organ transplant recipients who become pregnant should be managed by a multidisciplinary cardio-obstetrics team, including specialists in maternal and fetal medicine, cardiology and transplant medicine, as well as anesthesia, neonatology, psychology, genetics, and social services. With careful patient selection, pregnancy after HT can been managed safely. The purpose of this comprehensive review was to summarize the current evidence and recommendations surrounding preconception counseling, medical management and surveillance, maternal outcomes, breastfeeding, and remaining gaps in knowledge.
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Affiliation(s)
- Ersilia M Defilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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82
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Dines V, D'Costa M, Fidler M, Kattah A. The role of kidney biopsy in diagnosis of preeclampsia in kidney transplant patients. Hypertens Pregnancy 2020; 39:418-422. [PMID: 32744913 DOI: 10.1080/10641955.2020.1801717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this report is to review two patients who developed proteinuria in pregnancy after kidney transplant in order to highlight the importance of maintaining a broad differential and the diagnostic utility of kidney biopsy in this clinical scenario. METHODS Two cases of women with kidney transplants who presented with proteinuria in pregnancy are described and the literature is reviewed. RESULTS In both cases, a kidney biopsy allowed for prompt diagnosis and treatment. CONCLUSION Kidney biopsy should be considered an important diagnostic tool in this clinical scenario. ABBREVIATIONS ACE: angiotensin-converting enzyme; ESKD: end-stage kidney disease; FSGS: focal segmental glomerulosclerosis; RAAS: renin aldosterone angiotensin system.
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Affiliation(s)
- Virginia Dines
- Division of Nephrology and Hypertension, Mayo Clinic , Rochester, MN, USA
| | - Matthew D'Costa
- Division of Nephrology and Hypertension, Mayo Clinic , Rochester, MN, USA
| | - Mary Fidler
- Division of Anatomic Pathology, Mayo Clinic , Rochester, MN, USA
| | - Andrea Kattah
- Division of Nephrology and Hypertension, Mayo Clinic , Rochester, MN, USA
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83
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van Buren MC, Schellekens A, Groenhof TKJ, van Reekum F, van de Wetering J, Paauw ND, Lely AT. Long-term Graft Survival and Graft Function Following Pregnancy in Kidney Transplant Recipients: A Systematic Review and Meta-analysis. Transplantation 2020; 104:1675-1685. [PMID: 32732847 PMCID: PMC7373482 DOI: 10.1097/tp.0000000000003026] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/13/2019] [Accepted: 09/24/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND The incidence of pregnancy in kidney transplantation (KT) recipients is increasing. Studies report that the incidence of graft loss (GL) during pregnancy is low, but less data are available on long-term effects of pregnancy on the graft. METHODS Therefore, we performed a meta-analysis and systematic review on GL and graft function, measured by serum creatinine (SCr), after pregnancy in KT recipients, stratified in years postpartum. Furthermore, we included studies of nulliparous KT recipients. RESULTS Our search yielded 38 studies on GL and 18 studies on SCr. The pooled incidence of GL was 9.4% within 2 years after pregnancy, 9.2% within 2-5 years, 22.3% within 5-10 years, and 38.5% >10 years postpartum. In addition, our data show that, in case of graft survival, SCr remains stable over the years. Only within 2 years postpartum, Δ SCr was marginally higher (0.18 mg/dL, 95%CI [0.05-0.32], P = 0.01). Furthermore, no differences in GL were observed in 10 studies comparing GL after pregnancy with nulliparous controls. Systematic review of the literature showed that mainly prepregnancy proteinuria, hypertension, and high SCr are risk factors for GL. CONCLUSIONS Overall, these data show that pregnancy after KT has no effect on long-term graft survival and only a possible effect on graft function within 2 years postpartum. This might be due to publication bias. No significant differences were observed between pre- and postpartum SCr at longer follow-up intervals.
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Affiliation(s)
- Marleen C van Buren
- Department of Internal Medicine, Nephrology and Renal Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Anouk Schellekens
- Department of Obstetrics, Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, Utrecht
| | - T Katrien J Groenhof
- Department of Cardiovascular Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht
| | | | - Jacqueline van de Wetering
- Department of Obstetrics, Wilhelmina Children's Hospital Birth Center, University Medical Center Utrecht, Utrecht
| | - Nina D Paauw
- Department of Internal Medicine, Nephrology and Renal Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - A Titia Lely
- Department of Internal Medicine, Nephrology and Renal Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
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84
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Chmel R, Cekal M, Pastor Z, Chmel R, Paulasova P, Havlovicova M, Macek M, Novackova M. Assisted Reproductive Techniques and Pregnancy Results in Women with Mayer-Rokitansky-Küster-Hauser Syndrome Undergoing Uterus Transplantation: the Czech Experience. J Pediatr Adolesc Gynecol 2020; 33:410-414. [PMID: 32224249 DOI: 10.1016/j.jpag.2020.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/16/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE This study aimed to evaluate the reproductive potential of patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who were candidates for uterus transplantation (UTx) before inclusion in the experimental trial, and to summarize the existing experience with posttransplantation embryo transfers in functionally successful cases. DESIGN AND SETTING A prospective study at a tertiary medical center. PARTICIPANTS Ten pre-UTx women with MRKHS and 7 successful UTx cases. INTERVENTIONS AND MAIN OUTCOME MEASURES Ovarian stimulations, frozen embryo collection, embryo transfers, and incidence of pregnancy in MRKHS women in the pre- and posttransplantation periods. RESULTS The average number of ovarian stimulations to collect the required frozen embryos was 1.9 (1-3). On average, the number of aspirated oocytes was 16.4 (7-38), 12.6 (5-26) oocytes were fertilized, and 7.0 (1-18) embryos were cryopreserved per cycle. To date, the average number of embryo transfers per recipient was 4.9 (3-8), and the embryo transfer/pregnancy rate was 8.8% (3 of 34). Three pregnancies have been achieved to date, including a missed abortion in the 8th week, a birth in the 35th week, and an ongoing pregnancy in the 30th week. CONCLUSIONS Despite the small number of UTx cases, our data indicated that women with MRKHS showed a good response to ovarian stimulation and blastocyst formation. Although the procedures for fertilization, cryopreservation, and transfer of the embryos were standardized, the success rate per embryo transfer achieved in the study group has been low to date.
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Affiliation(s)
- Roman Chmel
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
| | - Milos Cekal
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zlatko Pastor
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Roman Chmel
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Petra Paulasova
- Department of Biology and Medical Genetics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Marketa Havlovicova
- Department of Biology and Medical Genetics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Milan Macek
- Department of Biology and Medical Genetics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Marta Novackova
- Department of Obstetrics and Gynaecology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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85
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An Underestimated Human Need After Renal Transplantation: Sexuality. SEXUALITY AND DISABILITY 2020. [DOI: 10.1007/s11195-020-09647-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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86
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Rahim MN, Heneghan MA. Reply. Liver Transpl 2020; 26:956-957. [PMID: 32168403 DOI: 10.1002/lt.25751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/05/2020] [Indexed: 01/13/2023]
Affiliation(s)
- Mussarat N Rahim
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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87
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Rahim MN, Long L, Penna L, Williamson C, Kametas NA, Nicolaides KH, Heneghan MA. Pregnancy in Liver Transplantation. Liver Transpl 2020; 26:564-581. [PMID: 31950556 DOI: 10.1002/lt.25717] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 12/26/2019] [Indexed: 02/06/2023]
Abstract
Pregnancy after liver transplantation (LT) is increasingly common and is a frequent scenario that transplant physicians, obstetricians, and midwives encounter. This review summarizes the key issues surrounding preconception, pregnancy-related outcomes, immunosuppression, and breastfeeding in female LT recipients. Prepregnancy counseling in these patients should include recommendations to delay conception for at least 1-2 years after LT and discussions about effective methods of contraception. Female LT recipients are generally recommended to continue immunosuppression during pregnancy to prevent allograft rejection; however, individual regimens may need to be altered. Although pregnancy outcomes are overall favorable, there is an increased risk of maternal and fetal complications. Pregnancy in this cohort remains high risk and should be managed vigilantly in a multidisciplinary setting. We aim to review the available evidence from national registries, population-based studies, and case series and to provide recommendations for attending clinicians.
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Affiliation(s)
- Mussarat N Rahim
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Lisa Long
- Department of Obstetrics, King's College Hospital, London, United Kingdom
| | - Leonie Penna
- Department of Obstetrics, King's College Hospital, London, United Kingdom
| | | | - Nikos A Kametas
- Fetal Medicine Research Unit, King's College Hospital, London, United Kingdom
| | - Kypros H Nicolaides
- Fetal Medicine Research Unit, King's College Hospital, London, United Kingdom
| | - Michael A Heneghan
- Institute of Liver Studies, King's College Hospital, London, United Kingdom
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88
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DeFilippis EM, Haythe J, Farr MA, Kobashigawa J, Kittleson MM. Practice Patterns Surrounding Pregnancy After Heart Transplantation. Circ Heart Fail 2020; 13:e006811. [DOI: 10.1161/circheartfailure.119.006811] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Pregnancy after heart transplantation (HT) is a concern for many female recipients. The International Society for Heart and Lung Transplantation has guidelines regarding reproductive health, but limited data exist regarding providers’ attitudes and practices surrounding pregnancy post-HT.
Methods:
We conducted an independent, confidential, voluntary, web-based survey sent electronically to 1643 United States heart transplant providers between June and August 2019.
Results:
There were 122 responses, the majority from cardiologists (n=85, 70%) and nurse or transplant coordinators (n=22, 18%). Thirty-one percent (n=37) of respondents indicated that pregnancy should be avoided in all HT recipients, and only 43% (n=52) reported that their center had a formal policy regarding pregnancy following HT. The most commonly reported contraindications included nonadherence (n=109, 89%), reduced left ventricular ejection fraction (n=104, 85%), coronary allograft vasculopathy (n=86, 70%), prior rejection (n=76, 62%), presence of donor-specific antibodies (n=69, 57%), and prior peripartum cardiomyopathy pretransplant (n=57, 47%). Respondent sex, specialty, transplant volume, or prior experience with pregnancy after HT were not associated with recommendations to avoid posttransplant pregnancy.
Conclusions:
Transplant providers’ attitudes regarding posttransplant pregnancy vary widely. Despite International Society for Heart and Lung Transplantation guidelines, a significant proportion indicates that pregnancy is contraindicated in all recipients and the majority of programs have no center-specific policy to manage such pregnancies. While the low response rate limits the generalizability of the findings, they do suggest that education on the feasibility of pregnancy post-HT is indicated as many recipients are of, or survive to, childbearing age.
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Affiliation(s)
- Ersilia M. DeFilippis
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York (E.M.D., J.H., M.F.)
| | - Jennifer Haythe
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York (E.M.D., J.H., M.F.)
| | - Maryjane A. Farr
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York (E.M.D., J.H., M.F.)
| | - Jon Kobashigawa
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (J.K., M.M.K.)
| | - Michelle M. Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (J.K., M.M.K.)
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89
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Esposito P, Garibotto G, Picciotto D, Costigliolo F, Viazzi F, Conti NE. Nutritional Challenges in Pregnant Women with Renal Diseases: Relevance to Fetal Outcomes. Nutrients 2020; 12:nu12030873. [PMID: 32213942 PMCID: PMC7146629 DOI: 10.3390/nu12030873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 02/07/2023] Open
Abstract
Pregnancy in women affected by chronic kidney disease (CKD) has become more common in recent years, probably as a consequence of increased CKD prevalence and improvements in the care provided to these patients. Management of this condition requires careful attention since many clinical aspects have to be taken into consideration, including the reciprocal influence of the renal disease and pregnancy, the need for adjustment of the medical treatments and the high risk of maternal and obstetric complications. Nutrition assessment and management is a crucial step in this process, since nutritional status may affect both maternal and fetal health, with potential effects also on the future development of adult diseases in the offspring. Nevertheless, few data are available on the nutritional management of pregnant women with CKD and the main clinical indications are based on small case series or are extrapolated from the general recommendations for non-pregnant CKD patients. In this review, we discuss the main issues regarding the nutritional management of pregnant women with renal diseases, including CKD patients on conservative treatment, patients on dialysis and kidney transplant patients, focusing on their relevance on fetal outcomes and considering the peculiarities of this population and the approaches that could be implemented into clinical practice.
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90
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Milić S, Tatalović T, Mikolašević I. Pre-existing liver disease in pregnancy: Cirrhosis, autoimmune hepatitis and liver transplantation. Best Pract Res Clin Gastroenterol 2020; 44-45:101668. [PMID: 32359683 DOI: 10.1016/j.bpg.2020.101668] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 01/22/2020] [Accepted: 02/18/2020] [Indexed: 01/31/2023]
Abstract
Liver disease during pregnancy is one of the least studied topics, but it links the interests of hepatologists, gynaecologists and family physicians. Approximately 3% of pregnant woman experience some type of liver disease. Liver disease can occur as a result of pregnancy, before pregnancy and coincidence-related during pregnancy. Pregnancy in women with pre-existing liver disease is essential that the clinicians are familiar with this disorder so they can respond promptly and appropriately in all of these situations. So, because of the complications for both mother and child, it is important that liver disease is recognized in a timely manner to avoid undesirable outcomes.
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Affiliation(s)
- Sandra Milić
- School of Medicine, University of Rijeka, Rijeka, Croatia; Department of Gastroenterology, University Hospital Center Rijeka, Rijeka, Croatia.
| | | | - Ivana Mikolašević
- School of Medicine, University of Rijeka, Rijeka, Croatia; Department of Gastroenterology, University Hospital Center Rijeka, Rijeka, Croatia.
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91
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Abstract
Chronic kidney disease represents a heterogeneous group of disorders characterized by alterations in the structure and function of the kidney. Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes, and these risks increase with the severity of the underlying renal dysfunction, degree of proteinuria, as well as the frequent coexistence of hypertension. Further, renal anatomic changes result in dilatation of the collecting system, and physiologic adaptations include alterations in the balance of vasodilatory and vasoconstrictive hormones, resulting in decreased systemic and renal vascular resistance, increased glomerular filtration rate, and modifications in tubular function. These alterations have important clinical implications and can make the diagnosis of renal compromise challenging. The effect of pregnancy on kidney disease may manifest as a loss of renal function, particularly in the context of concomitant hypertension and proteinuria, and chronic kidney disease, even when mild, contributes to the high risk of adverse pregnancy outcomes, including increased risks of preeclampsia, preterm delivery, and small-for-gestational age neonates. Strategies for optimization of pregnancy outcomes include meticulous management of hypertension and proteinuria where possible and the initiation of preeclampsia prevention strategies, including aspirin. Avoidance of nephrotoxic and teratogenic medications is necessary, and renal dosing of commonly used medications must also be considered. Mode of delivery in women with chronic kidney disease should be based on usual obstetric indications, although more frequent prenatal assessments by an expert multidisciplinary team are desirable for the care of this particularly vulnerable patient population. Obstetricians represent a critical component of this team responsible for managing each stage of pregnancy to optimize both maternal and neonatal outcomes, but collaboration with nephrology colleagues in combined clinics wherein both specialists can make joint management decisions is typically very helpful.
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92
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Madazlı R, Kaymak D, Alpay V, Erenel H, Dincer MT, Seyahi N. Evaluation of obstetric outcomes and prognostic significance of graft function in kidney transplant recipient pregnancies. Hypertens Pregnancy 2020; 39:89-94. [PMID: 32069132 DOI: 10.1080/10641955.2020.1727498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Objective: To evaluate obstetric and kidney outcomes in pregnancies with kidney transplantation.Methods: We retrospectively reviewed 32 singleton pregnancies in kidney transplant recipients. Obstetric outcomes were explored according to the estimated glomerular filtration rates (eGFR) of patients.Results: The incidences of fetal growth restriction, preeclampsia were 18.8% and 34.4%, respectively. There was a significant negative correlation between first-trimester eGFR and perinatal mortality (r = -0.546, p = .0.001) and composite adverse obstetric outcome (r = -0.415, p = .0.018).Conclusion: The degree of transplanted kidney function impairment at the beginning of pregnancy is the major determinant of pregnancy outcome.
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Affiliation(s)
- Riza Madazlı
- Cerrahpasa Medical Faculty, Department of Obstetrics and Gynecology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Didem Kaymak
- Cerrahpasa Medical Faculty, Department of Obstetrics and Gynecology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Verda Alpay
- Cerrahpasa Medical Faculty, Department of Obstetrics and Gynecology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hakan Erenel
- Cerrahpasa Medical Faculty, Department of Obstetrics and Gynecology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - M Tamer Dincer
- Cerrahpasa Medical Faculty, Department of Nephrology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Nurhan Seyahi
- Cerrahpasa Medical Faculty, Department of Nephrology, Istanbul University-Cerrahpasa, Istanbul, Turkey
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93
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Goto S, Fukushima R, Ozaki M. Anesthesia management in 14 cases of cesarean delivery in renal transplant patients-a single-center retrospective observational study. JA Clin Rep 2020; 6:10. [PMID: 32034536 PMCID: PMC7007450 DOI: 10.1186/s40981-020-0317-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/29/2020] [Indexed: 11/19/2022] Open
Abstract
Background The aim of this study was to investigate anesthesia management for cesarean delivery in renal transplant patients. Methods The details of anesthesia management, patient characteristics, surgical information, and renal and maternal outcomes were retrospectively investigated in 14 post-renal transplant patients who underwent cesarean delivery at a single university hospital between January 1, 2014, and August 31, 2018. Results Five patients were managed under general anesthesia, and nine cases were under regional anesthesia. Nine cases were emergency surgeries. The mean (SD) age was 35.5 (4.4) years, pregnancy body weight was 56.8 (10.0) kg, and gestational age was 33.3 (4.1) weeks. Nine cases were preterm deliveries. Five cases showed hypertension prior to pregnancy, and 13 patients showed hypertension before cesarean delivery. The preoperative creatinine level was 1.49 (0.53) mg/dL. The intraoperative maximum systolic/diastolic blood pressure was 170 (20)/102 (15) mmHg, and the intraoperative minimum systolic/diastolic blood pressure was 97 (13)/49 (12) mmHg. A total of six patients had either mean arterial pressure < 65 mmHg or required vasopressors. Serum creatinine remained unchanged after surgery compared with the preoperative level. Conclusion Cesarean delivery was often performed in post-renal transplant patients for preterm delivery or as emergency surgery, with a higher ratio of regional anesthesia to general anesthesia. Since both hypertension and hypotension are most likely to occur during cesarean delivery, circulation management can be difficult, and anesthesia should be managed so as to maintain sufficient renal perfusion and ensure postoperative renal function.
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Affiliation(s)
- Shunsaku Goto
- Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Risa Fukushima
- Department of Anesthesiology, Moriya Daiichi General Hospital, 1-17 Matsumaedai, Moriya-shi, Ibaraki, 302-0102, Japan.
| | - Makoto Ozaki
- Department of Anesthesiology, Tokyo Women's Medical University, Tokyo, Japan
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94
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Arabi Z, Ghalib B, Asmari I, Gafar M, Alam S, Abdulgadir M, AlShareef A, Rashidi A, Alruwaymi M, Altheaby A. Instructions for kidney recipients and donors (In English for medical providers and in Arabic for patients and donors). Avicenna J Med 2020; 10:41-53. [PMID: 32110549 PMCID: PMC7014992 DOI: 10.4103/ajm.ajm_120_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Medical providers are often asked by their kidney recipients and donors about what to do or to avoid. Common questions include medications, diet, isolation, return to work or school, pregnancy, fasting Ramadan, or hajj and Omrah. However, there is only scant information about these in English language and none in Arabic. Here, we present evidence-based education materials for medical providers (in English language) and for patients and donors (in Arabic language). These educational materials are prepared to be easy to print or adopt by patients, providers, and centers.
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Affiliation(s)
- Ziad Arabi
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Basmeh Ghalib
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Ibrahim Asmari
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed Gafar
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Syed Alam
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohamad Abdulgadir
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Ala AlShareef
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Awatif Rashidi
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed Alruwaymi
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdulrahman Altheaby
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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SARGIN A, KARAMAN S, CEYLAN Ş, AKDEMİR A, HORTU İ. Retrospective evaluation of anesthetic techniques in pregnant women with renal
transplantation. Turk J Med Sci 2019; 49:1736-1741. [PMID: 31655526 PMCID: PMC7518678 DOI: 10.3906/sag-1905-59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 10/17/2019] [Indexed: 02/05/2023] Open
Abstract
Background/aim The aim of this study was to evaluate anesthesia management in cesarean operation of pregnant women who underwent renal transplantation and the effects on postoperative renal function, retrospectively. Materials and methods After obtaining the approval of the ethics committee of our hospital, the records of pregnant women who underwent kidney transplantation and cesarean section between 2007 and 2017 were retrospectively analyzed. The patients’ demographic data, concomitant disease history, the treatment received, and type of anesthesia were retrospectively evaluated and recorded in the follow-up form. Results It was found that a total of 47 women who underwent renal transplantation had 47 live births by cesarean section. The mean age of the pregnant women was 30 ± 5.34 years. The mean time between renal transplantation and conception was 95.34 ± 55.02 months. It was found that 14 (29%) of a total of 47 patients had their first pregnancy. The number of patients with a gravidity of 4 and above was 9 (19%). A total of 21 (44.7%) pregnant women had spontaneous miscarriage. Five (10.6%) patients were treated with curettage for therapeutic purposes. Twenty-two (46%) of the patients whose immunosuppressive therapy was continuing were treated with azathioprine, tacrolimus, and prednisolone. The mean gestational age of delivery was 36.5 ± 1.59 weeks. The rate of prepregnancy hypertension diagnosis was 25.5% (n = 12), while the rate of developing gestational hypertension was 21.3% (n = 10). Spinal anesthesia was administered to 42 (91%) of 47 patients who underwent cesarean section. In the preoperative period, the mean value of serum blood urea nitrogen was 62.88 ± 41.97 mg/dL and the mean serum creatinine level was 3.21 ± 6.17 mg/dL. In the postoperative period, these values were 44.4 ± 29.9 mg/dL and 1.91 ± 1.63 mg/dL, respectively. When the pre- and postoperative serum urea and creatinine levels were compared, they were found to be lower in the postoperative period. However, there was no statistically significant difference (P > 0.05). The mean weight of the newborns was determined as 2707.3 ± 501.5 g. While the number of newborns with a low birth weight (<2500 g) was 18 (38%), among them 3 (0.6%) were below 2000 g. It was found that 36.2% (n = 17) of the newborns required intensive care. None of the patients developed graft rejection. Conclusion If there is no contraindication, regional anesthesia may be preferred in the first place for pregnant women with renal transplantation. We suggest that this method of anesthesia has some advantages in terms of maintaining postoperative renal function and higher Apgar scores in newborns with low birth weight.
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Affiliation(s)
- Asuman SARGIN
- Department of Anesthesiology and Reanimation, School of Medicine, Ege University, İzmirTurkey
| | - Semra KARAMAN
- Department of Anesthesiology and Reanimation, School of Medicine, Ege University, İzmirTurkey
| | - Şeyda CEYLAN
- Department of Anesthesiology and Reanimation, School of Medicine, Ege University, İzmirTurkey
| | - Ali AKDEMİR
- Department of Obstetrics and Gynecology, School of Medicine, Ege University, İzmirTurkey
| | - İsmet HORTU
- Department of Obstetrics and Gynecology, School of Medicine, Ege University, İzmirTurkey
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96
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Oliverio AL, Bragg-Gresham JL, Admon LK, Wright Nunes JA, Saran R, Heung M. Obstetric Deliveries in US Women With ESKD: 2002-2015. Am J Kidney Dis 2019; 75:762-771. [PMID: 31785826 DOI: 10.1053/j.ajkd.2019.08.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 08/30/2019] [Indexed: 12/31/2022]
Abstract
RATIONALE & OBJECTIVE Women with end-stage kidney disease (ESKD) have decreased fertility and are at increased risk for pregnancy complications. This study examined secular trends and outcomes of obstetric deliveries in a US cohort of women with ESKD. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Women aged 18 to 44 years with ESKD and registered in the US Renal Data System from 2002 to 2015. EXPOSURE ESKD modality (hemodialysis [HD], peritoneal dialysis, transplantation). OUTCOMES Infant delivery, preterm delivery, cesarean delivery. ANALYTICAL APPROACH Unadjusted delivery rates were expressed as number of delivering women per 1,000 patient-years among women aged 18 to 44 years within each year during the study period, stratified by ESKD modality. Logistic regression models were used to evaluate associations of delivery, preterm delivery, and cesarean delivery with patient characteristics. RESULTS The delivery rate in women undergoing HD and women with a kidney transplant increased from 2.1 to 3.6 and 3.1 to 4.6 per 1,000 patient-years, respectively (P<0.001 for each). The delivery rate in patients undergoing peritoneal dialysis was lower and did not increase significantly (P=0.9). Women with a transplant were less likely to deliver preterm compared with women undergoing HD (OR, 0.92; 95% CI, 0.84-1.00), though more likely have a cesarean delivery (OR, 1.18; 95% CI, 1.06-1.31). For deliveries occurring in the 2012 to 2015 period, 75% of women treated with HD were prescribed 4 or fewer outpatient HD treatments per week and 25% were prescribed 5-plus treatments per week in the 30 days before delivery. LIMITATIONS Ascertainment of outcomes and comorbid conditions using administrative claims data. CONCLUSIONS The delivery rate in women of reproductive age with ESKD increased from 2002 to 2015 among those treated with transplantation or HD. Women with a functioning transplant were less likely to deliver preterm, but more likely to have a cesarean delivery. Prescriptions for outpatient intensified HD for pregnant women with ESKD were infrequent in 2012 to 2015.
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Affiliation(s)
- Andrea L Oliverio
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI.
| | | | - Lindsay K Admon
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI
| | - Julie A Wright Nunes
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Rajiv Saran
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Department of Epidemiology, University of Michigan, Ann Arbor, MI
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
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98
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Wiles K, Chappell L, Clark K, Elman L, Hall M, Lightstone L, Mohamed G, Mukherjee D, Nelson-Piercy C, Webster P, Whybrow R, Bramham K. Clinical practice guideline on pregnancy and renal disease. BMC Nephrol 2019; 20:401. [PMID: 31672135 PMCID: PMC6822421 DOI: 10.1186/s12882-019-1560-2] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 09/16/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Kate Wiles
- NIHR Doctoral Research Fellow in Obstetric Nephrology, Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK.
| | - Lucy Chappell
- Guy's and St. Thomas' NHS Foundation Trust and King's College London, London, UK
| | | | - Louise Elman
- Expert Patient, c/o The Renal Association, Bristol, UK
| | - Matt Hall
- Nottingham University Hospital, Nottingham, UK
| | - Liz Lightstone
- Imperial College London and Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Catherine Nelson-Piercy
- Guy's and St. Thomas' NHS Foundation Trust and Imperial College Healthcare NHS Trust, London, UK
| | | | | | - Kate Bramham
- King's College Hospital NHS Foundation Trust and King's College London, London, UK
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99
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Bry C, Hubert D, Reynaud-Gaubert M, Dromer C, Mal H, Roux A, Boussaud V, Claustre J, Le Pavec J, Murris-Espin M, Danner-Boucher I. Pregnancy after lung and heart-lung transplantation: a French multicentre retrospective study of 39 pregnancies. ERJ Open Res 2019; 5:00254-2018. [PMID: 31687369 PMCID: PMC6819984 DOI: 10.1183/23120541.00254-2018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/29/2019] [Indexed: 11/30/2022] Open
Abstract
Pregnancy after lung and heart–lung transplantation remains rare. This French study deals with change in lung function after a pregnancy and the maternal and newborn outcomes. We retrospectively included 39 pregnancies in 35 women aged >20 years. Data on patients, course of pregnancies and newborns were collected from nine transplantation centres. Mean age at time of pregnancy was 28 years. Cystic fibrosis affected 71% of patients. Mean±sd time between transplantation and pregnancy was 63±44 months. 26 births occurred (67%) with a mean term of 36 weeks of amenorrhoea and a mean birthweight of 2409 g. Prematurity was observed in 11 cases (43%). Forced expiratory volume in 1 s was 83.9% of predicted before pregnancy and 77.3% of predicted 1 year after the end of pregnancy (p=0.04). 10 patients developed chronic lung allograft dysfunction after delivery. Nine patients died at a mean±sd time after transplantation of 8.2±7 years and a mean±sd time after pregnancy of 4.6±6.5 years. These data show that pregnancy remains feasible in lung and heart–lung transplant recipients, with more frequent maternal and newborn complications than in the general population. Survival in this cohort appears to be similar to the global survival observed in lung transplant recipients. Planned pregnancy and multidisciplinary follow-up are crucial. Pregnancy in lung and heart–lung recipients remains rare but possible. There is a significant decrease in FEV1 pre- and post-pregnancy, but overall outcomes are reassuring. Specialised, multidisciplinary follow-up is necessary.http://bit.ly/31iXxov
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Affiliation(s)
- Charlotte Bry
- Service de Pneumologie, CHU de Nantes, Nantes, France
| | | | - Martine Reynaud-Gaubert
- Centre de Ressource et de Compétences de la Mucoviscidose Adulte, Equipe de Transplantation Pulmonaire, CHU Nord, Marseille, France
| | - Claire Dromer
- Service de Pneumologie, CHU de Bordeaux, Bordeaux, France
| | - Hervé Mal
- Service de Pneumologie, Hôpital Bichat-Claude Bernard, Paris, France
| | - Antoine Roux
- Service de Pneumologie, Hôpital Foch, Suresnes, France
| | - Véronique Boussaud
- Service de Pneumologie, Hôpital Européen Georges Pompidou, Paris, France
| | - Johanna Claustre
- Clinique Universitaire de Pneumologie, Pôle Thorax et Vaisseaux, CHU de Grenoble, Grenoble, France
| | - Jérôme Le Pavec
- Service de Chirurgie Thoracique et Vasculaire, Centre Chirurgical Marie Lannelongue, Le Plessis Robinson, France
| | - Muriel Murris-Espin
- CRCM Adulte, Service de Pneumologie-Allergologie, CHU de Toulouse, Toulouse, France
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100
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Bachmann F, Budde K, Gerland M, Wiechers C, Heyne N, Nadalin S, Brucker S, Bachmann C. Pregnancy following kidney transplantation - impact on mother and graft function and focus on childrens' longitudinal development. BMC Pregnancy Childbirth 2019; 19:376. [PMID: 31646983 PMCID: PMC6813087 DOI: 10.1186/s12884-019-2496-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 09/09/2019] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Pregnancy after kidney transplantation has been considered as high risk for maternal and fetal complications. After careful patient selection successful pregnancies are described. Little is known about fetal outcomes and data is particularly scarce on childrens´ early development up to two years when born to kidney/-pancreas transplant recipients. Here, we analyzed maternal and fetal risk and evaluated graft function during pregnancy in transplanted women. We aimed to identify factors affecting the outcomes of mothers and their grafts during pregnancy and of children up to 2 years after delivery/ birth. METHODS All consecutive pregnancies in kidney/ kidney-pancreas recipients with live-born children from 2002 to 2016 were evaluated in two transplant centers (Charité Berlin/ University Tuebingen). All data was gathered from medical records. Impact of pregnancy on obstetrical risks, graft function and fetal development was evaluated. Additionally, for the first time development of children, including physical examination and assessment of neurological function were evaluated at 12 and 24 months. RESULTS Thirty-two pregnancies in 28 patients with a median duration of 34 gestational weeks (range, 24-38) were analyzed. 13 patients (46.4%) developed deterioration of kidney graft function > 10 ml/min during pregnancy. In majority, caesarean section was performed (75%). Twenty-five (78.1%) children were born prematurely, thereof (16%) < 28 weeks. Almost 70% had low birth weights (LBW) (< 2.500 g); median birth weight was 2.030 g. General health and physical constitution of children were unremarkable with normal development in 94% at 12 and 24 months of corrected age, respectively. CONCLUSION Despite the high rate of preterm birth and LBW, development up to two years was age-appropriate in this cohort. Due to low absolute numbers, increasing efforts in centralized counseling, diagnostics and committed specialist support are required. Decisive treatment of these high-risk patients in specialized units leading to better performance of these patients (mother/ fetus) is deemed superior. In order to confirm this, prospective studies on neonatal and pediatric outcomes with a standard-of-care comparator arm will be conducted.
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Affiliation(s)
- Friederike Bachmann
- Department of Nephrology and Medical Intensive Care medicine, Charité University medicine Berlin, Chariteplatz 1, 10117, Berlin, Germany.
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care medicine, Charité University medicine Berlin, Chariteplatz 1, 10117, Berlin, Germany
| | - Marie Gerland
- Department of Obstetrics and Gynecology, University Women's Clinic, University of Tuebingen, Calwerstrasse, 7, 72076, Tuebingen, Germany
| | - Cornelia Wiechers
- Department of Neonatology, University Children's Hospital Tuebingen, Calwerstrasse 7, 72076, Tuebingen, Germany
| | - Nils Heyne
- Department of Endocrinology and Diabetology, Angiology and Nephrology and Clinical Chemistry, University of Tuebingen, Otfried-Müllerstr. 10, 72076, Tuebingen, Germany
| | - Silvio Nadalin
- Department of General-, Visceral- and Transplant Surgery, University Hospital of Tuebingen, Tuebingen, Germany
| | - Sara Brucker
- Department of Obstetrics and Gynecology, University Women's Clinic, University of Tuebingen, Calwerstrasse, 7, 72076, Tuebingen, Germany
| | - Cornelia Bachmann
- Department of Obstetrics and Gynecology, University Women's Clinic, University of Tuebingen, Calwerstrasse, 7, 72076, Tuebingen, Germany
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