Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation

Anesthesia management in 14 cases of cesarean delivery in renal transplant patients-a single-center retrospective observational study

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.

Instructions for kidney recipients and donors (In English for medical providers and in Arabic for patients and donors)

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.

Retrospective evaluation of anesthetic techniques in pregnant women with renal transplantation

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.

Obstetric Deliveries in US Women With ESKD: 2002-2015

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.

Pregnancy after lung and heart-lung transplantation: a French multicentre retrospective study of 39 pregnancies

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

Pregnancy following kidney transplantation - impact on mother and graft function and focus on childrens' longitudinal development

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.

Racial disparities and factors associated with pregnancy in kidney transplant recipients in the United States

BACKGROUND

Although kidney transplant improves reproductive function in women with end-stage kidney disease (ESKD), pregnancy in kidney transplant recipients' remains challenging due to the risk of adverse maternal and fetal outcomes.

METHODS

We evaluated a retrospective cohort of 7,966 women who were aged 15-45 years and received a kidney transplant between January 1, 2005 and December 31, 2011 from the United States Renal Data System with Medicare as the primary payer for the entire three years after the date of transplantation. Unadjusted and adjusted rates of pregnancy in the first three post-transplant years were calculated, using Poisson regression for the adjustment. Factors associated with pregnancy, including race, were examined using logistic regression.

RESULTS

Overall, 293 pregnancies were identified in 7966 women. The unadjusted pregnancy rate was 13.8 per thousand person-years (PTPY) (95% confidence interval (CI), 12.3-15.5). Pregnancy rates were roughly constant in the years 2005-2011 except in 2005 and 2010. The rate of pregnancy was highest in Hispanic women (21.4 PTPY; 95% CI, 17.2-26.4) and Hispanic women had a higher likelihood of pregnancy as compared to white women (OR, 1.56; CI, 1.12-2.16). Pregnancy rates were lowest in women aged 30-34 years and 35-45 years at transplant, and women aged 30-34 years and 35-45 years at transplant were less likely to ever become pregnant during the follow-up (odds ratio [OR], 0.69; CI, 0.49-0.98 and OR, 0.14; CI 0.09-0.21 respectively) as compared to women aged 25-29 years at time of transplant. Women had higher rates of pregnancy in the second and third-year post-transplant (16.0 PTPY, CI 13.2-19.2 and 16.9 PTPY, CI 14.0-20.4) than in the first-year post-transplant (9.0 PTPY, CI 7.0-11.4). In transplant recipients, pregnancy was more likely in women with ESKD due to cystic disease (OR, 2.42; CI, 1.02-5.74) or glomerulonephritis (OR, 2.14; CI, 1.07-4.31) as compared to women with ESKD due to diabetes.

CONCLUSION

Hispanic race, younger age, and ESKD cause due to cystic disease or glomerulonephritis are significant factors associated with a higher likelihood of pregnancy. Pregnancy rates have been fairly constant over the last decade. This study improves our understanding of factors associated with pregnancy in kidney transplant recipients.

Perinatal outcomes of renal transplant pregnancies: a 22-year experience at a single tertiary referral center

Background: Renal transplantation not only prolongs survival but also improves quality of life and fertility, particularly in patients with end-stage renal disease. The aim of this study was to evaluate the renal and perinatal outcomes of pregnancy after renal transplantation at a high volume academic tertiary hospital.Methods: Fifty-one renal transplant patients (RTPs) who experienced pregnancy after transplantation and received care at Ege University Hospital between January 1995 and December 2017 were retrospectively identified. Data on demographics, comorbidities, and clinical perinatal outcomes were analyzed.Results: The median age of expectant mothers with renal transplantation was 30.51 ± 5.28 years (range 23-41). The mean interval between discontinuing birth control methods and the last menstrual period was 22 months. Preeclampsia occurred in six pregnancies (11.5%), and 43 of 52 pregnancies resulted in live births (82.6%). The mean gestational age at birth was 36.35 ± 2.36 weeks (range: 26-38). A total of 15 births were preterm deliveries (28.8%). Intrauterine growth retardation (IUGR) was detected in four cases. The mean birth weight was 2664.58 ± 613.99 g (range: 600-3.800 g). Twelve newborns were hospitalized in the neonatal intensive care unit (23%). A significant inverse correlation between birth weight and preconception serum creatinine level was found (p < .001; r = -0.532). An inverse correlation between the interval between transplantation and pregnancy and low postpartum serum creatinine level was established significantly (p < .05; r = -0.331). In addition, an inverse correlation between preconceptional serum creatinine and postpartum serum creatinine in the first year was found statistically significant (p < .001, r = -0.681).Conclusion: Even though pregnancy does not seem to adversely affect renal graft function, risks of perinatal as well as obstetrical complications should not be ignored. Pregnancies in RTPs should be followed closely by a multidisciplinary team of experts to minimize perinatal complications before and during pregnancy.

Management of reproductive health after cardiac transplantation

Pregnancy after cardiac transplantation poses immense challenges. Maternal risks include hypertensive disorders of pregnancy, rejection, and failure of the cardiac allograft that may lead to death. Fetal risks include potential teratogenic effects of immunosuppression and prematurity. Because of the high-risk nature of pregnancy in a heart transplant patient, management of reproductive health after cardiac transplantation should include preconception counseling to all women in the reproductive age group before and after cardiac transplantation. Reliable contraception is vital as nearly half of the pregnancies in this population are unintended. Despite the associated risks, successful pregnancies after cardiac transplantation have been reported. A multidisciplinary approach proposed in this review is essential for successful outcomes. A checklist for providers to guide management is provided.

Deficiencies in reproductive health counseling in liver transplant recipients

BACKGROUND

In liver transplant (LT) recipients of childbearing age, there is often rapid return of fertility post-transplant. Our aim was to determine whether healthcare providers are documenting reproductive health counseling in LT recipients.

METHODS

We performed a review of 365 LT recipients (164 female, 201 male) of childbearing age transplanted between 1994 and 2015 at a single center. We evaluated documentation of reproductive health counseling, content of the counseling and its provider.

RESULTS

Reproductive health counseling was documented in 7% of LT recipients (14% of females, 0.5% of males). The transplant team provided the counseling in 56%, obstetrics/gynecology in 35%, and primary care in 9%. Twenty-four post-LT pregnancies occurred; these were unplanned in 13%. Miscarriage/stillbirth occurred in 7/24 pregnancies (29%). Mycophenolic acid was used by 20% of female recipients at conception. Only age at transplant (P = 0.001) and post-LT pregnancy was associated with documentation of reproductive health counseling in female recipients (P = 0.0001).

CONCLUSION

Despite rapid return of fertility in reproductive-aged LT recipients, documentation of reproductive health counseling in this population is rare in men and women. This increases the potential for adverse maternal and fetal outcomes in this high-risk population.

Pregnancy After Renal Transplant: Single Center Experience From the Middle East in Patients Using Different Calcineurin Inhibitors

OBJECTIVES

Pregnancy after kidney transplant has a high risk for maternal and fetal complications; however, it can be successful if patients are properly selected. Here, we studied outcomes and complications of pregnancies in kidney transplant recipients who received calcineurin inhibitor-based immunosuppression.

MATERIALS AND METHODS

In this case control study, we reviewed patients who became pregnant between 2004 and 2017. For this analysis, each pregnancy was considered an event. We divided pregnancies into 2 groups according to calcineurin inhibitor-based maintenance immunosuppression: group 1 (49 pregnancies) received cyclosporine, and group 2 (33 pregnancies) received tacrolimus. Patients also received steroids and azathioprine. Patients had regular antenatal follow-up at the Hamed Alessa Organ Transplant Center (Kuwait) and in the maternity hospital (monthly until month 7 and then weekly until delivery).

RESULTS

Of 750 female kidney transplant recipients within childbearing potential, there were 82 pregnancies (10.9%) in 49 recipients (6.5%). Seventy-eight pregnancies were planned, and 4 pregnancies occurred while women were using contraception. There was 1 triple pregnancy, 5 double, and 76 single pregnancies. Two women had preeclampsia as maternal complication, 2 had uncontrolled hypertension, and 7 developed graft dysfunction. Forty-seven women (57.3%) had caesarean section, and the remaining had vaginal deliveries. Of 89 babies, 86 were viable (1 intrauterine fetal death and 2 abortions). Eight babies were delivered prematurely with low birth weight, and 2 needed incubators. Mean serum creatinine levels were 97.9 ± 24, 109 ± 38, 100 ± 39, 120 ± 46, and 115 ± 57 μmol/L at baseline, first, second, and third trimesters, and postpartum, respectively. Twelve patients showed high panel reactive antibodies but without donor-specific antibodies.

CONCLUSIONS

Posttransplant pregnancy can be successful in most renal allograft recipients, but the increased risk of fetal and maternal complications, including low birth weight, spontaneous abortus, and preeclampsia, should be considered.

Women's Reproductive Health for the Nephrologist

Women with chronic kidney disease (CKD) are faced with complex decisions and significant challenges during their reproductive years. Contraceptive choices have a variety of side effects that can disproportionately affect women with CKD, limiting choice. CKD itself and the therapies needed to treat severe disease can affect future fertility. When conception is desired, young women with CKD must plan meticulously because an ill-timed pregnancy can result in disease progression or flare and exposure of an unborn child to potentially teratogenic medications. Among women with CKD, pregnancy risks are substantial, with up to 10-fold higher risk for preeclampsia and 6-fold higher risk for preterm delivery. These pregnancy complications associated with inadequate placentation also increase maternal and newborn risks for cardiovascular morbidity and mortality and progression to kidney failure later in life. As such, it is the obligation of every nephrologist caring for women of reproductive age to provide guidance in the choice of methods to prevent unplanned pregnancies, to choose treatments that preserve fertility, and to participate in shared decision making that optimizes pregnancy timing and outcomes. In this perspective, we review the many challenges associated with reproductive counseling in women with CKD.

A New Life: Motherhood After Heart Transplantation. A Single-center Experience and Review of Literature

BACKGROUND

Pregnancy after heart transplantation (HTx) may expose the recipient to hemodynamic and immunologic risks and the newborn to toxic effects of immunosuppressive therapy. Adequate preconception counseling is crucial to identify optimal timing and to modify immunosuppressive therapy to minimize risks for both the mother and the fetus.

METHODS

We describe our experience with 12 pregnancies occurred in 11 women who had undergone HTx at our center.

RESULTS

Pregnancies ran without severe complications or rejections, and none of the babies have shown major defects at birth. However, as reported in the literature, weight at birth rated in lower range in most of the newborns, probably due to in utero cyclosporine exposure. Up to now, none of the babies showed clinical signs of heart disease, although more than half of the mothers had an inherited or familial cardiomyopathy.

CONCLUSIONS

Despite potential mother and fetal complications, successful pregnancy and delivery are possible after HTx, provided that optimum timing, close monitoring, and therapy adjustments are guaranteed. Becoming a mother appears to be an important achievement for young women after HTx, even when there is a risk to transmit an inheritable heart disease.

In Vitro Fertilization After Renal Transplantation: A Single-Center Experience

INTRODUCTION

Although kidney transplantation often increases the chances of fertility, the rate of infertile patients is still high. In vitro fertilization promises successful results for infertile renal transplantation patients. The purpose of this study was to analyze the experience of a single center.

METHODS

Patients were invited to complete a survey for their obstetric history. Documentation review included demographic and clinical characteristics of patients, like procedure records, follow-up complications, immunosuppression maintenance protocols, and pregnancy outcomes.

RESULTS

Thirteen patients were reached to complete the survey. The mean age of patients was 33 ± 4 years at in vitro fertilization (IVF). The median duration of infertility was 2 years. Twenty-four IVF sessions were applied to these 13 women with renal transplantation. The procedure failed in 13 of these sessions; and 8 women achieved 11 clinical pregnancies. There were 3 miscarriages and 2 stillbirths. Six women had live births with no neonatal deaths. One patient had a graft rejection after the IVF procedure. Serum creatinine level increased more than 30% in 3 patients after the IVF procedure, while 9 patients had a minimal or no change.

DISCUSSION

In our study, we evaluated the records of 13 patients with renal transplantation who had IVF procedures. Fortunately, more than half of these patients had live births with no neonatal deaths. In our opinion, our findings show that IVF procedures can be accepted as a promising method in patients with renal transplantation and need a therapy for fertility. Moreover, a 25% live-birth rate per procedure is also a satisfactory result.

Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review

BACKGROUND

Reproductive function in women with end stage renal disease generally improves after kidney transplant. However, pregnancy remains challenging due to the risk of adverse clinical outcomes.

METHODS

We searched PubMed/MEDLINE, Elsevier EMBASE, Scopus, BIOSIS Previews, ISI Science Citation Index Expanded, and the Cochrane Central Register of Controlled Trials from date of inception through August 2017 for studies reporting pregnancy with kidney transplant.

RESULTS

Of 1343 unique studies, 87 met inclusion criteria, representing 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years. The live-birth rate was 72.9% (95% CI, 70.0-75.6). The rate of other pregnancy outcomes was as follows: induced abortions (12.4%; 95% CI, 10.4-14.7), miscarriages (15.4%; 95% CI, 13.8-17.2), stillbirths (5.1%; 95% CI, 4.0-6.5), ectopic pregnancies (2.4%; 95% CI, 1.5-3.7), preeclampsia (21.5%; 95% CI, 18.5-24.9), gestational diabetes (5.7%; 95% CI, 3.7-8.9), pregnancy induced hypertension (24.1%; 95% CI, 18.1-31.5), cesarean section (62.6, 95% CI 57.6-67.3), and preterm delivery was 43.1% (95% CI, 38.7-47.6). Mean gestational age was 34.9 weeks, and mean birth weight was 2470 g. The 2-3-year interval following kidney transplant had higher neonatal mortality, and lower rates of live births as compared to > 3 year, and < 2-year interval. The rate of spontaneous abortion was higher in women with mean maternal age < 25 years and > 35 years as compared to women aged 25-34 years.

CONCLUSION

Although the outcome of live births is favorable, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

Unintended pregnancies and family planning among women after kidney or liver transplantation

Background: To evaluate the incidence of unplanned pregnancies in female organ transplant recipients.Methods: In a single-center cross-sectional study 252 women aged 18-45 years who underwent kidney or liver transplantation were asked to fill in a survey form.Results: 217 (86%) women were enrolled in the study. Fifty-three percent of women declared 181 pregnancies, of which 30% (54/181) were unplanned. Women more frequently consulted their conception with a doctor post-transplantation (74 versus 88%, p = .064). The number of unplanned pregnancies decreased post-transplantation (34 versus 20%, p = .051). The mean time elapsed from an organ transplant to unintended conception was 27.0 ± 12.5 (3.0-63.0) months. Women with longer (>24 months) rather than shorter (≤24 months) time elapsed from the transplant became pregnant less frequently (38 versus 15%, p = .060). In 70% (38/54) of unplanned pregnancies women did not use any birth control. All cases of conceptions within the post-transplant year were unintentional. Every third woman, who underwent the transplantation up to 1 year before the study enrolment, was unaware of the necessity to prevent the pregnancy.Conclusions: Although unwanted pregnancies occur more frequently in the early post-transplant period, it seems that women after kidney or liver transplantation seem to plan their pregnancies more carefully.

Sexual aspects of liver transplant candidates and recipients: evidence available in the literature1

OBJECTIVE

to analyze the evidence available in the literature on the alterations in the sexuality of candidates and recipients of liver transplantation.

METHOD

integrative review of the literature with search for primary studies in the databases MEDLINE (via PUBMED), CINAHL e LILACS, published in English, Portuguese and Spanish.

RESULTS

the 16 primary studies included were grouped into three categories: 1) female sexuality (n=5), 2) male sexuality (n=5) and 3) male and female sexuality (n=6). In category 1, the subjects investigated were contraception, pregnancy, sexual dysfunction, presence of gynecological symptoms and sexually transmitted infections. In category 2, the main focus of the studies was erectile dysfunction, sexual desire and satisfaction, and consequences of the immunosuppressive regimen with mycophenolic acid in men. In category 3, the evaluation of sexual function was the main topic.

CONCLUSION

the scientific evidence generated provides support to encourage health professionals to incorporate the topic of sexuality in the routine of care. Knowledge gaps were identified and new studies should be conducted in order to implement interventions to prevent, minimize and/or control changes related to the patient's sexuality.

Pregnancy in liver transplant recipients: A single center outcomes

AIM

Liver transplantation (LT) is the only effective treatment for the end-stage liver disease. Although pregnancy after LT is considered to be safe, these patients are difficult to manage for obstetricians. In this study, we aimed to determine maternal and fetal outcomes in pregnancies after LT.

METHODS

We conducted a retrospective review of liver transplant recipients who had received prenatal care and delivered pregnancy at İstanbul University İstanbul Medical Faculty, Department of Obstetrics and Gynecology January 2010 and January 2017.

RESULTS

A total of eight pregnancies were identified during the study period. The mean age of the patients at the time of LT was 25.6 ± 5.3 years (range 19-36 years), and the mean age at conception was 30.1 ± 5.2 years (range 25-41 years). The mean interval between transplantation and conception was 54.2 ± 18.6 months (range 24-82 months). There was no a miscarriage or a stillbirth was observed in any of patients. Mean birth week was 37.2 ± 2.1 weeks and mean birthweight was 2852 ± 562 g (range 2150-3470 g). Three of eight deliveries (37.5%) occurred before 37 gestational weeks. Preeclampsia was detected in one patient, one pregnancy was complicated by intrauterine growth retardation and one case with gestational diabetes mellitus. Mean postnatal follow-up period was 3.2 ± 2.4 years (range 1-7 years) and all of the babies were healthy. Graft rejection occurred in one patient after delivery.

CONCLUSION

More favorable pregnancy outcomes can be achieved with a multidisciplinary team and satisfactory counseling is mandatory either preconception and through the pregnancy to reduce maternal-fetal risks.

Pregnancy in Renal Transplant Recipients and Donors

Women with renal transplants have restoration of fertility with improved kidney function; however, pregnancy rates in renal transplant recipients appear to be lower than the general population, which might be influenced by patient choice. Women with renal transplants need to evaluate potential neonatal outcomes, graft outcomes, and risks to their own health to make informed decisions about conception. Pregnancy should be carefully planned in renal transplant recipients to reduce risk for graft loss, optimize pregnancy outcomes, and ensure immunosuppression regimes are nonteratogenic. Neonatal outcomes remain significantly worse for women with renal transplants than healthy controls, particularly for those with reduced graft function, hence prepregnancy, antenatal, and postpartum care of women with renal transplants should be guided by a multidisciplinary team of nephrologists and specialist obstetricians.

Reproductive health in women following abdominal organ transplant

Fertility is commonly impaired in women with end-stage kidney and liver disease, although most women will have restoration of fertility within 1 year of transplant. Family planning is therefore critical to discuss with reproductive-aged transplant recipients in the early posttransplant period, in order to ensure timely initiation of contraception, and optimal timing for conception. For women seeking pregnancy, the risks to the mother, graft, and baby should be discussed, including evaluation of immunosuppression safety and potential for adjusting medications prior to conception. With an increasing number of transplant patients now breastfeeding, immunosuppression safety in lactation continues to carry great importance.

Pregnancy after renal transplantation: a retrospective study at the military hospital of Tunis from 1992 to 2011

Introduction

Our study objective was to analyze the optimum conditions for pregnancy in kidney transplanted women. For that, we conducted a retrospective study was from 1992 to April 2011 about 17 pregnancies in 12 kidney transplanted patients followed in the Department of Obstetrics and Gynecology and Organ Transplant Unit of the Military Hospital of Tunis.

Methods

We studied nephrological parameters and obstetric pathologies encountered during pregnancy and the potential impact of pregnancy on graft. Our main outcome measures were: time between renal transplantation and conception, birth of a living child, renal graft defect.

Results

The mean age at the time of renal transplantation was 30.11 years. The average age at the time of conception is 34.23 years. The average time between renal transplantation and the occurrence of pregnancy was 46.94 months. More than 40% of pregnancies were not planned. Of the 17 pregnancies, 12 have advanced beyond the first trimester with 91.6% resulting in the birth of a living child. Toxemia was found in 60% of cases, low birth weight in 50%, preterm in 30% and intrauterine growth retardation in 20% of cases. Cesarean section was indicated in all cases. Graft survival was 90% with a mean of 6 years after delivery.

Conclusion

Pregnancy in kidney transplanted patients is a high-risk pregnancy, but pregnancy does not appear to affect graft function through certain conditions.

Pregnancy after heart transplantation: a well-thought-out decision? The Quebec provincial experience - a multi-centre cohort study

Despite reports of successful pregnancies in heart transplant (HTx) recipients, many centers recommend their patients against maternity. We reviewed our provincial experience of pregnancy in HTx recipients by performing charts review of all known gestations following HTx in the province of Quebec (Canada), stratified between planned and unplanned pregnancies. Long-term survival was compared to HTx recipient women of childbearing age who did not become pregnant. Eighteen pregnancies, 56% unplanned, occurred in eight patients, 10.1 (2.6-27.0) years after HTx. Immunosuppression was CNI-based, with a mean dose increase of 48.3% (tacrolimus) and 26.5% (cyclosporine), without rejection. Cardiometabolic complications were high compared to the general Canadian population, including preeclampsia (15.4% vs. 5.5%), hypertension (38.5% vs. 4.6%), and diabetes (15.4% vs. 5.6%). Mean gestational age was 35.1 (23.4-39.6) weeks (72.2% live births; 53.8% prematurity). Mean birthweight was 2418 (660-3612) g. Serum creatinine increased during pregnancy, becoming significant after delivery (P = 0.0239), and returning to preconception level in all but three patients within a year. After 4.6 (1.2-17.2) years of follow-up, two rejection episodes occurred in one patient. Long-term mortality was similar to overall HTx women (Kaplan-Meier; P = 0.8071). Pregnancy in HTx carries high cardiometabolic complications and decreased kidney function, but is feasible with acceptable outcomes and no impact on mother's survival.

Outcome of pregnancy after renal transplantation

AIM

The aim of our study was to compare the outcome of pregnancy in patients who became pregnant within 24 months of renal transplantation and patients who became pregnant more than 24 months after renal transplantation.

MATERIALS AND METHODS

The sample population of our prospective cohort study comprised of 44 patients who became pregnant following renal transplantation. In all cases, living donors were used for renal transplantation. The patients were allocated into either group A, which included 24 patients who became pregnant more than 24 months after renal transplantation, or group B, which included 20 patients who inadvertently became pregnant within 24 months of renal transplantation. Serum creatinine and 24-hour urinary protein concentration were measured each trimester. The incidences of preeclampsia and gestational diabetes, the timing and mode of delivery, the rate of preterm labor, and the mean fetal birth weight were determined.

RESULTS

The mean gestational ages in groups A and B were 35.8±3 weeks and 34.1±2.5 weeks, respectively. The mean fetal birth weights in groups A and B were 2,480±316 g and 2,284.5±262 g, respectively. These differences were statistically significant. The incidence of preterm labor was 45.8% in group A and 55% in group B. Proteinuria was significantly higher in group B during the third trimester of pregnancy. Preeclampsia occurred in 25% of the cases in group A and 30% of the cases in group B; this difference was not statistically significant. Gestational diabetes occurred in 2 out of 24 cases in group A and 2 out of 20 cases in group B. For group A and group B, normal vaginal delivery occurred in 58.3% and 55% of cases, respectively, and cesarean section was performed in 41.6% and 45% of cases, respectively.

CONCLUSION

A longer interval between renal transplantation and pregnancy is associated with better pregnancy outcome.

Pregnancy outcomes and impact of pregnancy on graft function in women after kidney transplantation

BACKGROUND

Kidney transplantation facilitates pregnancy in women with end-stage kidney disease; however, the impact of pregnancy on short and longer-term graft function is uncertain.

METHODS

Obstetric, fetal, and graft outcomes for pregnancies from a large Australian transplant unit (1976-2015) were reviewed.

RESULTS

There were 56 pregnancies in 35 women with mean age at conception 30.4 ± 0.6 years and mean transplant-pregnancy interval 5.5 ± 0.5 years. The live birth rate was 78.9%. Preterm birth (<37 weeks) occurred in 56.5%. Hypertensive disorders affected 76% of women (pre-eclampsia in 30%). Median prepregnancy serum creatinine (SCr) was 100 μmol/L (interquartile range (IQR), 80, 114 μmol/L). One-third had deterioration in graft dysfunction during pregnancy; of these, 63.2% did not return to baseline. At 2 years post-partum, median SCr was 96.4 μmol/L (IQR, 81.5-124.3). Women with prepregnancy SCr > 110 μmol/L had increased risk of pre-eclampsia (OR 4.4; 95% CI 1.2-16.8; P = .03), but not preterm birth (OR 5.4; 95% CI 0.5-53; P = .04) or low birth-weight babies (OR 1.2; 95% CI 0.5-2.9; P = .04). Women with SCr > 140 μmol/L preconception had worst SCr trajectory, including higher rates of graft loss.

CONCLUSIONS

Kidney transplantation pregnancies remain at high risk of obstetric complications, particularly pre-eclampsia. Prepregnancy graft function can be used to predict risk of adverse pregnancy outcomes and deterioration in graft function during and after delivery.

Anesthetic Considerations for the Parturient After Solid Organ Transplantation

Over the past 40 years, the success of organ transplantation has increased such that female solid organ transplant recipients are able to conceive and carry pregnancies successfully to term. Anesthesiologists are faced with the challenge of providing anesthesia care to these high-risk obstetric patients in the peripartum period. Anesthetic considerations include the effects of the physiologic changes of pregnancy on the transplanted organ, graft function in the peripartum period, and the maternal side effects and drug interactions of immunosuppressive agents. These women are at an increased risk of comorbidities and obstetric complications. Anesthetic management should consider the important task of protecting graft function. Optimal care of a woman with a transplanted solid organ involves management by a multidisciplinary team. In this focused review article, we review the anesthetic management of pregnant patients with solid organ transplants of the kidney, liver, heart, or lung.

Research priority setting in organ transplantation: a systematic review

Barriers to access and long-term complications remain a challenge in transplantation. Further advancements may be achieved through research priority setting with patient engagement to strengthen its relevance. We evaluated research priority setting in solid organ transplantation and described stakeholder priorities. Databases were searched to October 2016. We synthesized the findings descriptively. The 28 studies (n = 2071 participants) addressed kidney [9 (32%)], heart [7 (25%)], liver [3 (11%)], lung [1 (4%)], pancreas [1 (4%)], and nonspecified organ transplantation [7 (25%)] using consensus conferences, expert panel meetings, workshops, surveys, focus groups, interviews, and the Delphi technique. Nine (32%) reported patient involvement. The 336 research priorities addressed the following: organ donation [43 priorities (14 studies)]; waitlisting and allocation [43 (10 studies)]; histocompatibility and immunology [31 (8 studies)]; immunosuppression [21 (10 studies)]; graft-related complications [38 (13 studies)]; recipient (non-graft-related) complications [86 (14 studies)]; reproduction [14 (1 study)], psychosocial and lifestyle [49 (7 studies)]; and disparities in access and outcomes [10 (4 studies)]. The priorities identified were broad but only one-third of initiatives engaged patients/caregivers, and details of the process were lacking. Setting research priorities in an explicit manner with patient involvement can guide investment toward the shared priorities of patients and health professionals.

Pregnancy in chronic kidney disease and kidney transplantation

Chronic kidney disease (CKD) affects up to 6% of women of childbearing age in high income countries, and is estimated to affect 3% of pregnant women. Advanced renal dysfunction, proteinuria, hypertension, and poorly controlled underlying primary renal disease are all significant risks for adverse maternal, fetal, and renal outcomes. In order to achieve the best outcomes, it is therefore of paramount importance that these pregnancies are planned, where possible, to allow the opportunity to counsel women and their partners in advance and to optimize these risks. These pregnancies should be deemed high risk and they require close antenatal monitoring from an expert multidisciplinary team. We discuss the effect of pregnancy on CKD, and also current guidelines and literature with specific reference to transplantation, autoimmune disease, and medication use in pregnancy. We also discuss the benefits of prepregnancy counseling and give practical recommendations to advise pregnant women with renal disease.