Pregnancy after kidney transplantation

Pharmacologic Treatment of Noninfectious Uveitis

Uveitis encompasses a spectrum of diseases whose common feature is intraocular inflammation, which may be infectious or noninfectious in etiology (Nussenblatt and Whitcup 2010). Infectious causes of uveitis are typically treated with appropriate antimicrobial therapy and will not be discussed in this chapter. Noninfectious uveitides are thought have an autoimmune component to their etiology and are thus treated with anti-inflammatory agents.

The role of the body in end-stage kidney disease in young adults: Gender, peer and intimate relationships

OBJECTIVES

To understand how the physical body, and changes in the physical body, influence peer and intimate relationships and parenting in young adults on renal replacement therapies (RRT).

METHODS

Qualitative interview data from 40 young adults aged 16-30 years with end-stage kidney disease (ESKD), first diagnosed aged 0-19 years, were analysed using modified grounded theory.

FINDINGS

Alternating modalities of RRT had a 'yo-yo' effect on the bodies of interviewees, repeatedly reconstructing them as either 'transplanted' bodies, often initially obese, or as 'dialysis' bodies', often underweight. Invisible somatic changes had a major impact on gendered social identity, making intimate social relationships and parenthood problematic. Prepubertal onset interviewees were generally less successful in forming partnerships than those with postpubertal onset; and interviewees on dialysis were likely to postpone partnering until they were transplanted. Social networks were essential for finding a partner, but male interviewees had fewer networks than females. Parenthood was particularly challenging for female interviewees.

CONCLUSIONS

In ESKD, life-saving RRT brings major changes to the body. These adversely affect social relationships and family formation during the crucial period of early adulthood. Effects vary according to age of onset, RRT modality, and gender, with those who were ill before puberty and those on dialysis worst affected.

[Uterine transplantation: is there a real demand?]

OBJECTIVES

To study the demand there is for uterus transplantation (UTx).

PATIENTS AND METHODS

Recent media coverage of developments in UTx prompted associations of patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and of women suffering from UI to contact us. We sent them anonymous questionnaires devised to sound out their attitude towards UTx and towards adoption and gestational surrogacy (GS). A clinical psychologist also carried out a qualitative discourse analysis.

RESULTS

Sixty patients answered the questionnaire. Thirty-eight patients were married or living with a male partner. Seven patients had had a hysterectomy. Fifty-one patients had uterine agenesis. Of the 60 patients, 19 and 21, respectively, had ruled out the option of adoption or GS, and 11 would not envisage either possibility. Thirty-five patients were willing to take part in a clinical study into UTx despite the uncertainty of the outcome and the potential risks involved. Of these 35 volunteers, 23 were in a heterosexual relationship and aged ≤35 years.

DISCUSSION AND CONCLUSION

For women with UI the condition is all the more distressing because there is no medical solution for it. UTx could hold out hope for some of these patients despite the complexity of the procedure and the attendant risks. Because of the feelings of vulnerability engendered by UI, any UTx programme should provide full information to patients and ensure they are carefully screened and selected.

Management of pregnancy in the post-cardiac transplant patient

Over the past 10 years, heart transplantation survival has increased among transplant recipients. Because of improved outcomes in both congenital and adult transplant recipients, the number of male and female patients of childbearing age who desire pregnancy has also increased within this population. While there have been many successful pregnancies in post-cardiac transplant patients reported in the literature, long-term outcome data is limited. Decisions regarding the optimal timing and management of pregnancy in male and female post-cardiac transplant patients are challenging and should be coordinated by a multidisciplinary team of healthcare providers. Pregnant patients will need to be counseled and monitored carefully for complications including rejection, graft dysfunction, and infection. This review focuses on preconception counseling for both male and female cardiac transplant recipients. The maternal and fetal risks during pregnancy and the postpartum period, including risks to the fetus fathered by a male cardiac transplant recipient will be reviewed. It also provides a brief summary of our own transplant experience and recommendations for overall management of pregnancy in the post-cardiac transplant recipient.

Risk of obstetrical complications in organ transplant recipient pregnancies

Pregnancy after kidney and liver transplantation is becoming relatively common, although, in both groups, maternal complications are higher than in the general population. Both mean gestational age and mean birthweight seems significantly greater for liver transplant versus kidney transplant recipients and the risk of hypertension during pregnancy seems also lower for liver transplant than kidney transplant recipients. Thus, sequelae of chronic kidney diseases have stronger adverse effects on pregnancy, leading to a higher occurrence of adverse neonatal complications. Also, gestation in heart recipients may be complicated and preeclampsia seems to occur more frequently. However, the transplanted heart seems to adapt well to changes caused by pregnancy, such as increased cardiac workload and output, and elevated maternal oxygen consumption. More problematic is pregnancy in lung transplant recipients. Spontaneous pregnancy and healthy childbirth after bone marrow grafting is relatively rare due to irradiation, but, if gestation occurs, no specific problems have been identified. Obstetrical syndromes associated with transplantation reflect the pathology of defective deep placentation, where conversion of uterine spiral arteries remains largely restricted to the decidual segment. The myometrial segments of the uteroplacental arteries have a unique vascular memory and are at great risk to develop obstructive, atherosclerotic lesions. A similar increased risk of complications already existed in pregnancies during the years before transplantation. The effect of immunosuppressive therapy remains speculative. Therefore, the main target for improving the outcome of pregnancy in women at risk is the strict antihypertensive treatment from the earliest stage of pregnancy.

Tacrolimus placental transfer at delivery and neonatal exposure through breast milk

AIM(S)

The current investigation aims to provide new insights into fetal exposure to tacrolimus in utero by evaluating maternal and umbilical cord blood (venous and arterial), plasma and unbound concentrations at delivery. This study also presents a case report of tacrolimus excretion via breast milk.

METHODS

Maternal and umbilical cord (venous and arterial) samples were obtained at delivery from eight solid organ allograft recipients to measure tacrolimus and metabolite bound and unbound concentrations in blood and plasma. Tacrolimus pharmacokinetics in breast milk were assessed in one subject.

RESULTS

Mean (±SD) tacrolimus concentrations at the time of delivery in umbilical cord venous blood (6.6 ± 1.8 ng ml(-1)) were 71 ± 18% (range 45-99%) of maternal concentrations (9.0 ± 3.4 ng ml(-1)). The mean umbilical cord venous plasma (0.09 ± 0.04 ng ml(-1)) and unbound drug concentrations (0.003 ± 0.001 ng ml(-1)) were approximately one fifth of the respective maternal concentrations. Arterial umbilical cord blood concentrations of tacrolimus were 100 ± 12% of umbilical venous concentrations. In addition, infant exposure to tacrolimus through the breast milk was less than 0.3% of the mother's weight-adjusted dose.

CONCLUSIONS

Differences between maternal and umbilical cord tacrolimus concentrations may be explained in part by placental P-gp function, greater red blood cell partitioning and higher haematocrit levels in venous cord blood. The neonatal drug exposure to tacrolimus via breast milk is very low and likely does not represent a health risk to the breastfeeding infant.

[Placental transfer of drugs]

With more than 830,000 live births in France, a great number of pregnant women are concerned by a treatment during pregnancy and many questions revolve around appreciating medication-related risks during pregnancy. The human placenta is the interface between mother and fetus and remains difficult to study for ethical reasons. Placental transfer of drugs from mother to fetus is dependent on their physicochemical properties, maternal and fetal factors and placental factors. The human placental perfusion model is the only experimental model to study human placental transfer of drugs in organized placental tissue. In vitro models utilizing cell cultures are mostly limited to the investigation of cellular toxicity along pregnancy or specific transfer mechanisms, such as their interaction with transporters. Taking advantage of the complementarity of these models, it will be possible to develop a rational use of drugs during this period.

Chronic kidney disease in pregnancy

Parturients with renal insufficiency or failure present a significant challenge for the anesthesiologist. Impaired renal function compromises fertility and increases both maternal and fetal morbidity and mortality. Close communication amongst medical specialists, including nephrologists, obstetricians, neonatologists and anesthesiologists is required to ensure the safety of mother and child. Pre-existing diseases should be optimized and close surveillance of maternal and fetal condition is required. Kidney function may deteriorate during pregnancy, necessitating early intervention. The goal is to maintain hemodynamic and physiologic stability while the demands of the pregnancy change. Drugs that may adversely affect the fetus, are nephrotoxic or are dependent on renal elimination should be avoided.

Pregnancy management of diabetic renal transplant patients

Advances in medical care and options for medications for diabetic kidney transplant recipients have allowed for successful pregnancies to be carried to full term. End-stage renal disease leads to impaired fertility. Fertility is restored 1 to 6 months after a successful kidney transplant. Poor glycemic control near the conception period leads to a higher incidence of major fetal malformations and spontaneous abortion. Preconception counseling about risks of medications, control of comorbid conditions, stability of allograft function, and potential risks to mother, fetus, and allograft has to be done. Close and careful monitoring of mother, fetus, and allograft is important in ensuring a good outcome.

A comparison of the outcome of pregnancies after liver and kidney transplantation

BACKGROUND

Pregnancies are an issue difficult to manage in recipients of solid organ grafts. Whereas most studies report on individual women who have received transplants, we retrospectively studied all gestations of women with liver (LT) or kidney transplants (KT) from October 1988 to August 2010 at one major transplantation center in Germany and compared the outcome.

METHODS

A total of 115 gestations in 37 women with LT and in 34 women with KT were identified. Mean age and time between transplantation and gestation were comparable in both groups.

RESULTS

Whereas 81 (70%) of all gestations were successful, 15 (13%) were terminated, and there were 19 (17%) spontaneous abortions and 2 (2%) intrauterine deaths. The rate of live births in women with LT was higher than that in women with KT (48/62 [77%] vs. 32/53 [62%], P=0.05). Fetal abnormalities were observed in two newborns in women with LT. The duration of successful gestations was lower in women with KT than in women with LT (35 months [range, 26-41 months] vs. 39 months [range, 26-40 months], P<0.001). Preterm births occurred in 37% of all women, but predominantly in women with KT associated with a lower birth weight of the newborns. Preeclampsia occurred in 18 women, of whom 14 were women with KT. We observed 10 women with rejection episodes associated to pregnancy; these were 8 women with LT and 2 women with KT.

CONCLUSIONS

Pregnancies after liver or kidney transplantation had an acceptable outcome with 70% live births. Remarkably, maternal comorbidity and complications during gestation were more frequent in women with KT affecting newborn birth weight. There were more rejections in women with LT than in women with KT.

Pregnancy outcomes among solid organ transplant recipients in British Columbia

OBJECTIVE

Since 1954, over 14 000 women have given birth after having had an organ transplantation. Unfortunately, some women and physicians remain misinformed about the feasibility and outcomes of pregnancy post transplantation. Our primary objective was to assess their perceptions and difficulties with regard to becoming pregnant. Our secondary objectives were to determine the incidence of pregnancies among transplant recipients in British Columbia and any maternal, graft, or fetal complications.

METHODS

From 1997 to 2007 in British Columbia, there were over 500 female recipients of solid organ transplants. We surveyed recipients in this group who were of child-bearing age.

RESULTS

One hundred forty of 295 (47%) eligible recipients responded: 44 of these women had attempted pregnancy after transplant, and 31 women gave birth to 47 children. One half of the respondents planned to have children post transplant; 108 of 140 (77%) had no children before transplant. One quarter of the respondents were advised against pregnancy by their physician, and 33% of these women found a new physician to support their pregnancy. Rates of miscarriage (27%), rejection (21%), and prematurity (65%) were higher than expected. Infections were rare, and no birth defects or noteworthy health problems in the offspring were reported.

CONCLUSIONS

Overall, pregnancy appears to be safe following solid organ transplantation, but careful monitoring and counselling are recommended.

Maternity and lung transplantation: cases in Spain

We contacted and analyzed the data of 18 lung transplant recipients who had had children. The complications we detected included: hypertension (50%), diabetes mellitus (21%), preeclampsia (13%), infection (21%), rejection (30%), loss of graft function (23%) and a lower percentage of live births than in transplant recipients of other organs. Other aspects to keep in mind are: the potential risk for fetal alterations (caused by drugs used as prophylaxis against rejection crossing the placental barrier); greater risk for infection and alterations in drug levels due to changes in metabolism typical of pregnancy and postpartum period. We describe the two cases in Spain of female lung transplant recipients who have had children after transplantation. Although pregnancy in these cases can have a similar evolution as in non-transplanted women, doctors should recommend their transplanted patients to avoid becoming pregnant, while explaining the high risk of both fetal and maternal morbidity and mortality after transplantation.

Pregnancy in renal transplantation: Recipient and donor aspects in the Arab world

OBJECTIVE

There are many kidney transplant recipients and living donors of reproductive age, and the prevalence of pregnancies in kidney transplant recipients can reach 55% in the Middle Eastern countries. Living kidney donation is predominant in this region. As the risks and outcomes of pregnancy should be a part of counselling for both recipients and donors, we reviewed available reports on maternal and foetal outcomes in these particular populations.

METHODS

Information was obtained from retrospective analyses of a large database, and from single-centre reports indexed in PubMed on pregnancy in donors and kidney transplant recipients. The keywords used for the search included 'fertility', 'kidney disease', 'pregnancy', 'maternal/foetal outcomes', 'kidney transplant recipient', 'immunosuppression side-effects', 'living donor' and 'Arab countries'.

RESULTS

Pregnancies in kidney transplant recipients are most successful in those with adequate kidney function and controlled comorbidities. Similarly to other regions, pregnant recipients in the Middle East had a higher risk of pre-eclampsia (26%) and gestational diabetes (7%) than in the general population. Caesarean section was quite common, with an incidence rate of 61%, and the incidence of pre-term birth reached 46%.

CONCLUSIONS

Most living donors can have successful pregnancies and should not be routinely discouraged. Women who had pregnancies before and after donation were more likely to have adverse maternal outcomes (gestational diabetes, hypertension, proteinuria, and pre-eclampsia) in the latter, but no adverse foetal outcomes were found after donation. The evaluation before donation should include a gestational history and counselling about the potential risks.

Therapeutic value of prenatal rapamycin treatment in a mouse brain model of tuberous sclerosis complex

Epileptic seizures, particularly infantile spasms, are often seen in infants with tuberous sclerosis complex (TSC) soon after birth. It is feared that there are long-term developmental and cognitive consequences from ongoing, frequent epilepsy. In addition, the hallmark brain pathology of TSC, cortical tubers and giant cells are fully developed at late gestational ages. These observations have led us to examine the benefit of prenatal rapamycin in a new fetal brain model of TSC. In this Tsc1(cc) Nes-cre(+) mouse model, recombination and loss of Tsc1 in neural progenitor cells leads to brain enlargement, hyperactivation of mTOR, and neonatal death on P0 due to reduced pup-maternal interaction. A single dose of prenatal rapamycin given to pregnant dams (1 mg/kg, subcutaneous) rescued the lethality of mutant mice. This one dose of prenatal rapamycin treatment reduced hyperactivation of the mTOR pathway in the mutant brain without causing apparent pregnancy loss. Continued postnatal rapamycin beginning at day 8 extended the survival of these mice to a median of 12 days with complete suppression of hyperactive mTOR. However, the rapamycin-treated mutants developed enlarged brains with an increased number of brain cells, displaying marked runting and developmental delay. These observations demonstrate the therapeutic benefit and limitations of prenatal rapamycin in a prenatal-onset brain model of TSC. Our data also suggest the possibility and limitations of this approach for TSC infants and mothers.

Pregnancy in women with renal disease. Yes or no?

Women with renal disease who conceive and continue pregnancy, are at significant risk for adverse maternal and fetal outcomes. Although advances in antenatal and neonatal care continue to improve these outcomes, the risks remain proportionate to the degree of underlying renal dysfunction.The aim of this article, is to examine the impact of varying degrees of renal insufficiency on pregnancy outcome, in women with chronic renal disease and to provide if possible, useful conclusions whether and when, a woman with Chronic Kidney Disease (CKD), should decide to get pregnant.This article, reviews briefly the normal physiological changes of renal function during pregnancy, and make an attempt to clarify the nature and severity of the risks, in the settings of chronic renal insufficiency and end stage renal disease, including dialysis patients and transplant recipients.

Topics in transplantation medicine for general nephrologists

Before transplantation, the general nephrologist is the primary resource for potential kidney transplantation recipients. After transplantation, the general nephrologist is increasingly managing transplant medications and complications. We provide evidence-based management strategies for common clinical issues. Linking our approach with the data allows the clinician to explore each subject in greater depth to tailor care to individual patients.

The effect of spontaneous twin pregnancy on renal transplant function and haemodynamics

Spontaneous twin pregnancy is rare in renal transplant recipients, and confers a significant risk, in terms of both transplant dysfunction and fetal complications. Physiological changes in renal haemodynamics may assist in predicting a favourable outcome, but have not been previously reported in these circumstances. We present a case of a successful outcome for both mother and babies, and detail the effects of the pregnancy on transplant function and haemodynamics within the transplant kidney. Without beneficial circumstances, twin pregnancy may be a high risk in renal transplant recipients and may lead to a poor outcome for both transplant and fetuses.

Hydronephrosis in a pregnant renal transplant patient

Although pregnancy can cause hydronephrosis in native kidneys, renal transplant dysfunction during pregnancy due to obstruction is rare. A 22-week pregnant renal transplant patient presented with deteriorating renal function (serum creatinine 5.22 mg/dL from 2.07 mg/dL 3 weeks previously). Ultrasound showed transplant hydronephrosis with the graft compressed between the gravid uterus and liver. Percutaneous nephrostomy was placed with improvement in graft function. The nephrostomy remained in situ for the rest of the pregnancy. The nephrostomy was removed postpartum with no recurrence of hydronephrosis and subsequent transplant biopsy showed no evidence of rejection. The gravid uterus may obstruct a transplanted kidney.

Immunization and transplantation--what is new and what is coming?

Infections represent an important risk for pediatric transplant recipients. Many infections are preventable through immunization, and ongoing studies are working on increasing the number of available vaccines for these children either before or after transplantation. We examine new immunization schedules (such as pertussis vaccines in teenagers) and newly available vaccines (such as human papillomavirus vaccine), and suggest how to deliver them in pediatric transplant candidates or recipients. We also review less common vaccines (such as encephalitis vaccines), and possible vaccines of the future that could have an important clinical impact in these children, such as CMV or EBV vaccines.