Pregnancy after organ transplantation: a report from the UK Transplant pregnancy registry

[Liver transplantation and pregnancy]

Management during their sexual life of patients with a liver transplantation is a more or less common situation depending centers. Based on literature review, a focus on management of recipient women was conducted, from contraception to pregnancy, describing the complications related to the status of transplant recipient, but also those that may be related to immunosuppressive agents. If fertility and access to contraception are only slightly modified by graft, complications related to graft or immunosuppressive drugs can affect the pregnancy. On the maternal side, hypertension and preeclampsia are more common, as well as renal dysfunction, iatrogenic diabetes and bacterial or viral infections, acute rejection and graft loss do not appear to be influenced by pregnancy. The fetus is also exposed to risks such as induced prematurity and IUGR. Pregnancy in recipients of hepatic grafts therefore requires joint follow-up by transplant specialist and perinatologist, which leads in most cases to successful outcome for mother and child.

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.

Cyclosporine A exposure during pregnancy in mice: effects on reproductive performance in mothers and offspring

BACKGROUND

Pregnancies after organ transplantation and under immunosuppressive treatment are associated with slightly elevated risks for obstetric and post-natal complications but can usually be managed well. However, little is known about the effects of intrauterine exposure (IUE) to immunosuppressants in the growing and adult offspring. One major issue is the potentially negative effects of immunosuppressive medication on reproduction. This study investigates the effect of exposure during pregnancy to the most commonly used immunosuppressant in organ transplantation, cyclosporine A (CsA), on the reproductive outcome in mothers and offspring.

METHODS

Female C57CBA-F1 mice received 0, 10, 20 or 30 mg/kg bodyweight of CsA daily by subcutaneous mini-osmotic pumps during mating and pregnancy. Blood concentrations of CsA, implantation rates, resorption rates and fetal weights were analysed. In addition, female and male mice exposed to CsA in utero were mated to unexposed partners and pregnancy outcomes were analysed.

RESULTS

Direct maternal exposure to CsA at high doses reduced implantation rates and fetal survival. IUE to CsA reduced adolescent growth but did not affect fertility, although a reduction in birthweight was seen in offspring of females exposed to CsA in utero.

CONCLUSIONS

CsA exposure during pregnancy correlates with impaired reproductive outcome, but offspring fertility is not affected. The cause of reduction in adolescent weight gain and low birthweight in offspring of females exposed to CsA in utero need further investigation.

De novo HLA sensitization and antibody mediated rejection following pregnancy in a heart transplant recipient

Here we report a case wherein both donor-specific and third-party, paternal, HLA class II specific antibodies developed following a spontaneous miscarriage resulting in antibody-mediated rejection in a patient who had undergone an orthotopic cardiac transplant six years earlier.

Pregnancy outcomes among liver transplant recipients in the United States: a nationwide case-control analysis

Liver transplant recipients and their infants may have an increased risk of obstetric complications. Our objective was to describe pregnancy outcomes in women with a prior transplant from a population-based perspective. We analyzed the 1993-2005 US Nationwide Inpatient Sample database to identify obstetric hospitalizations among transplant recipients (n = 206) and controls matched by age, hospital, and year (n = 4060). The effect of prior transplantation on maternal and fetal outcomes was evaluated with regression models with adjustments for patient and hospital factors, including admission to a transplant center. Between 1993 and 2005, 146 delivery admissions among liver transplant recipients were identified. Cesarean deliveries were more common among transplant recipients (38% versus 24%; P = 0.0001); however, this difference was not significant after multivariate adjustment [OR (odds ratio) = 0.87; 95% confidence interval (CI) = 0.60-1.27]. Maternal mortality was similar among cases and controls (0% versus 0.02%; P = 1.00), but transplant patients had higher rates of fetal mortality (6.3% versus 2.0%; P = 0.0006), antepartum admission (OR = 2.27; 95% CI = 1.59-3.25), and maternal (OR = 2.63; 95% CI = 1.82-3.80) and fetal complications (OR = 2.49; 95% CI = 1.68-3.70). Gestational hypertension (30% versus 9%; P < 0.0001) and postpartum hemorrhage (8% versus 3%; P = 0.009) were more common among transplant recipients; their infants had higher rates of prematurity (27% versus 11%; P < 0.0001), distress (10% versus 5%; P = 0.005), and growth restriction (5% versus 2%; P = 0.05) but not congenital anomalies. Hospitalization in a transplant center ( approximately 50%) was associated with similar obstetric outcomes. In conclusion, although most pregnancy outcomes are favorable, liver transplant recipients and their infants have an increased risk of obstetric complications. Additional studies evaluating mechanisms aimed at reducing these complications are necessary.

KDIGO clinical practice guideline for the care of kidney transplant recipients

The 2009 Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline on the monitoring, management, and treatment of kidney transplant recipients is intended to assist the practitioner caring for adults and children after kidney transplantation. The guideline development process followed an evidence-based approach, and management recommendations are based on systematic reviews of relevant treatment trials. Critical appraisal of the quality of the evidence and the strength of recommendations followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. The guideline makes recommendations for immunosuppression, graft monitoring, as well as prevention and treatment of infection, cardiovascular disease, malignancy, and other complications that are common in kidney transplant recipients, including hematological and bone disorders. Limitations of the evidence, especially on the lack of definitive clinical outcome trials, are discussed and suggestions are provided for future research.

Pregnancy and maternal outcomes among kidney transplant recipients

Fertility rates, pregnancy, and maternal outcomes are not well described among women with a functioning kidney transplant. Using data from the Australian and New Zealand Dialysis and Transplant Registry, we analyzed 40 yr of pregnancy-related outcomes for transplant recipients. This analysis included 444 live births reported from 577 pregnancies; the absolute but not relative fertility rate fell during these four decades. Of pregnancies achieved, 97% were beyond the first year after transplantation. The mean age at the time of pregnancy was 29 +/- 5 yr. Compared with previous decades, the mean age during the last decade increased significantly to 32 yr (P < 0.001). The proportion of live births doubled during the last decade, whereas surgical terminations declined (P < 0.001). The fertility rate (or live-birth rate) for this cohort of women was 0.19 (95% confidence interval 0.17 to 0.21) relative to the Australian background population. We also matched 120 parous with 120 nulliparous women by year of transplantation, duration of transplant, age at transplantation +/-5 yr, and predelivery creatinine for parous women or serum creatinine for nulliparous women; a first live birth was not associated with a poorer 20-yr graft or patient survival. Maternal complications included preeclampsia in 27% and gestational diabetes in 1%. Taken together, these data confirm that a live birth in women with a functioning graft does not have an adverse impact on graft and patient survival.

The pregnancy rate and live birth rate in kidney transplant recipients

Fertility is one of the potential benefits for women undergoing kidney transplantation; however, population-based information about the likelihood of pregnancy and successful fetal outcome is not available. In this observational study of 16 195 female kidney transplant recipients aged 15-45 years in the United States between 1990 and 2003, we determined the pregnancy rate and live birth rate using Medicare claims data from the first three posttransplant years. The pregnancy rate was 33 per thousand female transplant recipients between 1990 and 2003 and progressively declined from 59 in 1990 to 20 in 2000. The live birth rate between 1990 and 2003 was 19 per thousand female transplant recipients and declined in parallel with the pregnancy rate. Despite a decrease in therapeutic abortions over time, the proportion of pregnancies resulting in fetal loss (45.6%) remained constant during the study due to an increase in spontaneous abortions and other causes of fetal loss. The pregnancy rate in kidney transplant recipients was markedly lower and declined more rapidly than reported in the general American population during the same period. The live birth rate was substantially lower than reported in voluntary registries of transplant recipients, and the proportion of pregnancies resulting in unexpected fetal loss increased over time.

Pregnancy after transplantation

The National Transplantation Pregnancy Registry (NTPR) was established in 1991 to study the outcomes of pregnancies in female transplant recipients and pregnancies fathered by male transplant recipients. Data from the NTPR have helped to endorse the reassurances from publications of smaller experiences that successful pregnancies are possible in the transplant population. In our last review for this journal (2000), we noted that important future issues would include the reassessment of prepregnancy guidelines, gestational and organ-specific problems, the role of new immunosuppressive drugs, and the long-term effects of pregnancy on both graft and child. Data collected by the NTPR over the last 7 years have addressed these issues, thus providing additional information for health care providers of transplant recipients of childbearing age. There has been some refinement of prepregnancy guidelines, but there is a need for additional data collection so that organ-specific outcomes and risks can further be identified. To date, the outcomes of the children followed have been encouraging, and specific remote effects have not been identified, but continued surveillance is still vital. Of special concern are the new immunosuppressive drugs, specifically for mycophenolate mofetil (CellCept, Roche Laboratories Inc., Nutley, New Jersey), where data reported to the NTPR and through postmarketing surveillance have shown an increased incidence of nonviable outcomes and a specific pattern and increased incidence of malformation in the newborn, which has resulted in a pregnancy category change. Newer information points to an increased need for vigilance among centers and continued monitoring of pregnancy outcomes in this population. As the first reported pregnancy after transplantation occurred in a kidney recipient 50 years ago, in March 1958, this review also highlights the first reported pregnancies in other solid organ recipients.

The experience of pregnancy after renal transplantation: pregnancies even within postoperative 1 year may be tolerable

BACKGROUND

To identify factors related with successful pregnancy in renal transplant recipients and the effect of pregnancy on long-term graft outcome.

METHODS

The study group consisted of 48 women who conceived after undergoing renal transplantation (total pregnancies 74). The control group consisted of 187 nonpregnant female renal transplant recipients.

RESULTS

Mean ages at the time of transplantation and pregnancy were 28.0+/-4.0 years and 31.6+/-4.1 years, respectively. The mean interval from transplantation to pregnancy was 40.2+/-27.1 months. Outcomes included 49 live births, 12 terminations, 9 miscarriages, 3 stillbirths, and 1 ectopic pregnancy. Eleven of the 74 pregnancies (15%) were within 1 year of transplantation, resulting in seven live births, two miscarriages, and two terminations. Live births were associated with younger age at the time of transplantation (relative risk, 0.75; P=0.042) and younger age at the time of pregnancy (relative risk, 0.76; P=0.022). Graft failure rate from transplantation to end of follow-up did not differ between the pregnant and nonpregnant groups (19% vs. 21%, P=0.688). The 10-year graft survival rates were also similar in the 11 women who became pregnant less than or equal to 12 months after transplantation and the 37 who became pregnant more than 12 months after transplantation (78.8% vs. 78.6%, P=0.941).

CONCLUSION

A younger age at transplantation and at pregnancy was associated with a greater likelihood of a live birth. Transplantation to conception interval of less than 1 year was not associated with a greater number of adverse pregnancy events when compared with the group with transplantation to conception interval greater than 1 year.

Pregnancy after kidney transplantation

Reproductive success is a common, expected outcome for male and female recipients of solid-organ transplants. Men can father children, and women can become pregnant and carry the fetus to delivery. There are, however, important maternal and fetal complications that need to be considered to provide optimal care to the mother and her infant. Although pregnancy is common after the transplantation of all solid organs, guidelines for optimal counseling and clinical management are limited. This review discusses information to help the physician counsel the kidney transplant recipient about risks of pregnancy for the mother and the fetus and provides information to help guide treatment of the pregnant transplant recipient.

Outcome of 234 pregnancies in 140 renal transplant recipients from five middle eastern countries

OBJECTIVE

To study the pregnancy and offspring outcomes in postrenal transplant recipients.

METHODS

This is a retrospective case-note review study investigating the outcome of 234 pregnancies in 140 renal transplant recipients from five different Middle Eastern countries.

RESULTS

Of the overall pregnancies 74.4% were successful albeit with high prevalences of preterm and Caesarean deliveries (40.8% and 53%, respectively). The mean serum creatinine did not rise significantly during pregnancy in the group as a whole but did so in patients who had serum creatinine of or above 150 micromol/L at the beginning of their pregnancies. The mean birth weight was (2,458 g) with 41.3% of the newborns being of low birth weight (<2,500 g). The prevalences of stillbirths were 7.3% and of spontaneous abortion was 19.3%. Preeclampsia and gestational diabetes were observed in 26.1% and 2% of pregnancies, respectively.

CONCLUSIONS

In the presence of good allograft function, the majority of pregnancies in renal transplant recipients have a good outcome but with increased incidence of preeclampsia, reduced gestational age, and low birth weights. Patients with baseline serum creatinine of above 150 micromol/L have an increased risk of allograft dysfunction resulting from the pregnancy.

Pregnancy after liver transplantation

There have been great strides in transplant medicine over the past few decades, and hundreds of pregnancies have now been reported in liver transplant recipients. Information on pregnancy in transplant patients has been collected through case reports, retrospective center-specific studies, and voluntary registries. Overall, favorable pregnancy outcomes have been reported for these patients. Pregnancy complications, however, are more common in liver transplant recipients than in the general population. Accordingly, pregnancies in liver transplant recipients should be followed by a multidisciplinary team involving both maternal fetal medicine specialists and transplant physicians. This chapter outlines the available data on the maternal and obstetrical outcomes of pregnancies in liver transplant recipients, and will review guidelines for management of these high-risk pregnancies.

Pregnancy after thoracic organ transplantation

A growing number of heart, heart-lung, or lung transplant recipients are women of reproductive age. Fertility and pregnancy are important issues in this group of patients and often pose complex medical, psychosocial, and ethical problems. Many successful pregnancy outcomes have been reported following heart or lung transplantation. Nevertheless, these patients are at risk of certain maternal, fetal, and neonatal complications, including hypertension, preeclampsia, infection, preterm birth, and low birth weight. The physiological changes that occur in pregnancy are generally well tolerated by patients who have undergone thoracic organ transplant(s). The risk of allograft rejection during and after pregnancy is significant, and it is important to maintain an adequate level of immunosuppression. Pregnancies among lung transplant recipients are at higher risk for certain complications. The rate for graft rejection, independent of pregnancy status, is higher in this population. The long-term graft and patient outcomes citing a 50% 5-year mortality will be critical while counseling these patients regarding the impact of pregnancy on survival, and the ability to participate in raising the child. A multi-disciplinary team, involving specialists in maternal fetal medicine, cardiology or pulmonary medicine, transplant medicine, anesthesiology, high-risk nursing, neonatology, psychology, genetics, and social service, is crucial to the care of these patients. This team approach should be initiated at the time of pretransplant and preconception counseling and be continued through the prenatal and postpartum periods. The management plan should be individualized according to the status of the mother, the fetus, and the allograft. For most cases, given the need for close collaboration and frequent monitoring, these patients are best managed at their primary transplant institution in collaboration with local or referring physicians.

Immunosuppressant therapy in pregnant organ transplant recipients

Transplant recipients are becoming pregnant with increasing frequency, and successful pregnancy outcomes have now been reported for women with all types of solid organ transplants. To prevent rejection of the transplanted organ, these patients are maintained on a life-long immunosuppressive regimen that must also be continued through pregnancy. Controlled human studies of the safety of these drugs have not been conducted, and knowledge regarding the pharmacokinetics of these medications in pregnancy is limited. Significant experience and safety data regarding the use of some of the more common immunosuppressants in pregnancy have, however, been accumulated from large case series and national registries. These observational studies suggest that successful pregnancy outcomes are possible in female organ transplant recipients, although sporadic adverse outcomes have been reported after immunosuppressant use in pregnancy. In this chapter, we will outline the information available regarding the use of immunosuppressive medications in pregnant transplant recipients as well as general concepts regarding fetal exposure to immunosuppressants.

Pregnancy in renal transplant recipients

Women with renal disease face increasing infertility and high-risk pregnancy as they approach end-stage renal disease due to uremia. Renal transplantation has provided these patients the ability to return to a better quality of life, and for a number of women who are of child bearing age with renal disease, it has restored their fertility and provided the opportunity to have children. But, although fertility is restored, pregnancy in these women still harbors risk to the mother, graft, and fetus. Selected patients who have stable graft function can have successful pregnancies under the supervision of a multidisciplinary team involving maternal fetal medicine specialists and transplant nephrologists. Careful observation and management are required to optimize outcome for mother and fetus.