Pregnancy outcomes in kidney transplant recipients: a systematic review and meta-analysis

What we do and do not know about women and kidney diseases; questions unanswered and answers unquestioned: Reflection on World Kidney Day and International Woman's Day

Chronic kidney disease affects approximately 10% of the world's adult population: it is within the top 20 causes of death worldwide, and its impact on patients and their families can be devastating. World Kidney Day and International Women's Day in 2018 coincide, thus offering an opportunity to reflect on the importance of women's health and specifically their kidney health, on the community, and the next generations, as well as to strive to be more curious about the unique aspects of kidney disease in women so that we may apply those learnings more broadly. Girls and women, who make up approximately 50% of the world's population, are important contributors to society and their families. Gender differences continue to exist around the world in access to education, medical care, and participation in clinical studies. Pregnancy is a unique state for women, offering an opportunity for diagnosis of kidney disease, but also a state where acute and chronic kidney diseases may manifest, and which may impact future generations with respect to kidney health. There are various autoimmune and other conditions that are more likely to impact women with profound consequences for child bearing, and on the fetus. Women have different complications on dialysis than men, and are more likely to be donors than recipients of kidney transplants. In this editorial, we focus on what we do and do not know about women, kidney health, and kidney disease, and what we might learn in the future to improve outcomes worldwide.

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.

Growth of children born to renal transplanted women

Neonates born to transplanted mothers are exposed to immunosuppressive drugs during gestation and have a higher risk of being born prematurely and small for gestational age than the general population. We have prospectively followed up 27 children born to renal transplanted mothers from a single center and 31 healthy children born at term with adequate weight for gestational age. Comparisons of weight and length measurements were made at birth, 1 month (±0.9), 3 months (±1.0), 6 months (±1.0), 9 months (±1.5), and 12 months (±1.49) of age. There were a high rate of prematurity (51.9%) and neonates small for gestational age (40.7%) in the transplant group. At birth, in the transplant group, 28% of neonates had subnormal z-scores for weight and 40%, low z-scores for length. However, at 6 months of age, no significant differences were noticed in mean weight-for-age z-scores between groups (weight -0.43 vs -0.03; length -0.53 vs -0.08). At 12 months of age, comparable mean length-for-age z-scores were observed in both groups (weight 0.01 vs 0.27; length -0.07 vs 0.26).

CONCLUSION

Despite high rates of premature births and neonates small for gestational age in the transplant group, there was a good recovery of growth during the first year.. What is Known: • Children born to renal transplanted mothers are exposed to immunosuppressive drugs during gestation [4]. • They have high risk of premature birth and fetal growth restriction, immune alterations at birth, and risk of hospitalization for infection in the first months of life [5]. What is New: • Despite high rates of premature birth and neonates small for gestational age, these infants had good growth recovery by 1 year of age.

Modified human uterus transplantation using ovarian veins for venous drainage: the first report of surgically successful robotic-assisted uterus procurement and follow-up for 12 months

OBJECTIVE

To report the 12-month results of the first human uterus transplantation case using robot-assisted uterine retrieval. This type of transplantation may become a treatment for permanent uterine factor infertility.

DESIGN

Case study.

SETTING

University hospital.

PATIENT(S)

A 22-year-old woman with complete müllerian agenesis who underwent a previous surgery for vaginal reconstruction. The live uterine donor was her mother.

INTERVENTION(S)

The uterus transplantation procedure consisted of robot-assisted uterine procurement, orthotopic replacement and fixation of the retrieved uterus, revascularization, and end-to-side anastomoses of bilateral hypogastric arteries and ovarian-uterine vein to the bilateral external iliac arteries and veins.

MAIN OUTCOME MEASURE(S)

Data from preoperative investigations, surgery, and follow-up (12 months).

RESULT(S)

The duration of the donor and recipient surgeries were 6 and 8 hours, 50 minutes, respectively. No immediate perioperative complications occurred in the recipient or donor. The recipient experienced menarche 40 days after transplant surgery, and she has had 12 menstrual cycles since the surgery. No rejection episodes occurred in the recipient.

CONCLUSION(S)

These results demonstrate the feasibility of live-donor uterine transplantation with a low-dose immunosuppressive protocol and the role of DaVinci robotic assistance during human uterine procurement.

CLINICAL TRIAL REGISTRATION NUMBER

XJZT12Z06.

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.

Association Between the Fertile Period and Live Birth Post-Kidney Transplantation: A Retrospective Single-Center Cohort Study

BACKGROUND

Despite restoration of fertility after kidney transplantation, the benefit is limited in female kidney recipients. Our objective is to determine the reasons for this discrepancy.

METHODS

We evaluated 315 women who underwent kidney transplantation from 1983 to 2015 (a median of age at transplantation [10th-90th percentile] of 32 years [7-55 years]); 230 recipients between the ages of 15 to 49 years old as of March 2016 were observed.

RESULTS

We experienced 10 abortions and 21 live births from our 23 recipients and 2 abortions and 7 live births in 7 recipients from other transplant center. The live birth rate was 8.9 per 1000 female transplant recipients of childbearing age. Seven recipients received either treatments of artificial insemination or in vitro fertilization. Average age at pregnancy was 33.2 ± 3.2 years old, and the fertile period post-transplantation was longer in recipients with live births than those without live births (14.1 ± 7.1 vs 9.9 ± 7.3 years, P < .05). In 42.9% of recipients with live birth, pregnancy-induced hypertension was observed in the last trimester. The gestational age and the average birth weight were 32.8 ± 5.0 months and 2184 ± 632 g, respectively. During follow-up of 14.5 years, there was one case of graft loss, which is a rate of 2.5 per 1000 female recipients.

CONCLUSION

Although pregnancy complications are often observed in kidney recipients, graft survival is less influenced by pregnancy. Importantly, kidney disease at childbearing age disrupts pregnancy even after kidney transplantation.

Age-Based Reproductive Healthcare Stereotype Threat (HCST) as a Stressor Affecting Prenatal Mental Health in Pregnant Women of Advanced Maternal Age: Measurement, Process, Outcomes, and Interactions with Ethnicity/Race, SES, and Other Social Identities

PURPOSE OF REVIEW

Reproductive health, and pregnancy more specifically, is the first critical link between generations. Beginning with this first critical link, pregnancy acts as a domino, affecting the expression of genes and determining the lifespan mental and physical health and reproductive potential of offspring and, likely, of subsequent generations. Given the powerful intergenerational domino that is pregnancy, the development of innovative models to enhance reproductive health and outcomes is an invaluable public health investment.

RECENT FINDINGS

While U.S. pregnancy and birth outcomes have improved dramatically since the 1960s- including substantial progress within the past 15 years, largely catalyzed by the Healthy People initiative-group-based disparities remain. What's more, social change and medical advancements have led to an evolving window of female reproductive age. Despite becoming more common, being an older expectant mother remains a stigmatized social identity. The concept of healthcare stereotype threat (HCST) is introduced in relation to reproductive health. Stereotype threat is a situational predicament in which an individual who possesses a stigmatized social identity fears confirming negative group-based stereotypes. HCST is a healthcare-specific form of stereotype threat, arising out of stereotypes that are salient in healthcare settings. It is hypothesized that the experience of age-based reproductive HCST is an overlooked stressor affecting prenatal mental and physical health among women of advanced maternal age.

SUMMARY

The hypothesized process of age-based reproductive HCST is described; outcomes and consequences are discussed; interactions with ethnicity/race, SES, and other aspects of social identity are considered; and strategies for prevention and intervention are explored, including active and passive shifts in three areas: (1) internally, in both providers and patients; (2) in the external environment, or the physical healthcare setting itself; and (3) within interpersonal interactions that occur within healthcare settings, particularly between physicians and patients. Implications for gynecological, infertility, and obstetric care and improving the reproductive outcomes of older women are discussed.

Pregnancy outcomes after kidney transplantation-A single-center experience in Taiwan

OBJECTIVE

This study investigated the pregnancy outcomes of women who had undergone kidney transplantations from 1992 to 2013 in a single medical center.

MATERIALS AND METHODS

Records for patients who had undergone kidney transplantations between 1992 and 2013 at National Taiwan University Hospital, Taipei, Taiwan were retrospectively reviewed, and data on obstetric conditions, neonatal outcomes, and maternal and neonatal complications were collected.

RESULTS

Data for a total of 15 pregnancies in 13 women who had undergone kidney transplantation between 1992 and 2013 were included in this study. The live birth rate was 87%. The mean gestational age was 35.4 ± 3.2 weeks, and the mean birth body weight was 2208.8 ± 678.8 g. Forty percent of the neonates were small for their gestational age (< 10(th) percentile); 53.3% of the pregnancies resulted in preterm deliveries (< 37 weeks); and 26.7% of the neonates needed Neonatal Intensive Care Unit admission. The prevalence rates of preeclampsia and gestational diabetes were 23.0% and 13.3%, respectively.

CONCLUSION

The pregnancy outcomes after kidney transplantation were favorable and the mean birth body weight was 2208.8 ± 678.8 g at 35.4 ± 3.2 weeks gestational age. However, the maternal and neonatal complication rates were still high, such as preterm labor, preeclampsia, and small for gestational age.

Living Donor Uterus Transplant and Surrogacy: Ethical Analysis According to the Principle of Equipoise

The uterus is the most recent addition to the list of organs that can be successfully transplanted in humans. This article analyzes living donor uterus transplantation according to the ethical principle of equipoise. A comparison is made between living donor uterus transplantation and gestational surrogate motherhood. Both are solutions to absolute uterine infertility that allow the transfer of genetic material from intended parents to a child. The analysis concludes that living donor uterus transplantation does not violate the ethical principle of equipoise and should be considered an ethically acceptable solution to absolute uterine infertility.

Preeclampsia in kidney transplanted women; Outcomes and a simple prognostic risk score system

Women pregnant following kidney transplantation are at high risk of preeclampsia. Identifying the effects of preeclampsia on pregnancy outcome and allograft function in kidney transplanted women, and predicting which women will require more targeted follow-up and possible therapeutic intervention, could improve both maternal and neonatal outcome. In this retrospective cohort study of all pregnancies following kidney transplantation in Norway between 1969 and 2013, we used medical records to identify clinical characteristics predictive of preeclampsia. 175 pregnancies were included, in which preeclampsia was diagnosed in 65. Pregnancies with preeclampsia had significantly higher postpartum serum creatinine levels, higher risks of preterm delivery, caesarean delivery, and small for gestational age infants. In the final multivariate model chronic hypertension (aOR = 5.02 [95% CI, 2.47–10.18]), previous preeclampsia (aOR = 3.26 [95% CI, 1.43–7.43]), and elevated serum creatinine (≥125 μmol/L) at the start of pregnancy (aOR = 5.79 [95% CI, 1.91–17.59]) were prognostic factors for preeclampsia. Based on this model the risk was 19% when none of these factors were present, 45–59% risk when one was present, 80–87% risk when two were present, and 96% risk when all three were present. We suggest that the risk of preeclampsia in pregnancies in kidney transplanted women can be predicted with these variables, which are easily available at the start of pregnancy.

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.

Overview of Pregnancy in Renal Transplant Patients

Kidney transplantation offers best hope to women with end-stage renal disease who wish to become pregnant. Pregnancy in a kidney transplant recipient continues to remain challenging due to side effects of immunosuppressive medication, risk of deterioration of allograft function, risk of adverse maternal complications of preeclampsia and hypertension, and risk of adverse fetal outcomes of premature birth, low birth weight, and small for gestational age infants. The factors associated with poor pregnancy outcomes include presence of hypertension, serum creatinine greater than 1.4 mg/dL, and proteinuria. The recommended maintenance immunosuppression in pregnant women is calcineurin inhibitors (tacrolimus/cyclosporine), azathioprine, and low dose prednisone; and it is considered safe. Sirolimus and mycophenolate mofetil should be stopped 6 weeks prior to conception. The optimal time to conception continues to remain an area of contention. It is important that counseling for childbearing should start as early as prior to getting a kidney transplant and should be done at every clinic visit after transplant. Breast-feeding is not contraindicated and should not be discouraged. This review will help the physicians in medical optimization and counseling of renal transplant recipients of childbearing age.

[Sexuality, fertility and pregnancy after kidney transplantation]

AIMS

To describe sexuality and fertility alterations secondary to chronic kidney disease and their outcomes after renal transplantation.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: erectile dysfunction; impotence; sexuality; pregnancy; fertility; renal transplantation. Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 706 articles. After reading titles and abstracts, 76 were included in the text, based on their relevance.

RESULTS

The observed prevalence of erectile dysfunction is high in men with chronic kidney disease. The causes of erectile dysfunction are numbers and its origin is often multifactorial. Most of the time, kidney transplantation improves sexuality and the management of erectile dysfunction in transplanted men is similar to the general population. Improvement in sexuality in men and women after kidney transplantation may conduct to pregnancy. The outcomes of pregnancy after transplantation are quite good in absence of risk factors such as time to pregnancy less than 1 year after transplantation, uncontrolled high blood pressure, and decreased renal function of the graft. Adaptation of immunosuppression may be required to avoid any teratogenicity for the fetus.

CONCLUSION

Kidney transplantation improves sexuality and fertility in men and women with chronic kidney disease.

Timing of Pregnancy After Kidney Transplantation and Risk of Allograft Failure

The optimal timing of pregnancy after kidney transplantation remains uncertain. We determined the risk of allograft failure among women who became pregnant within the first 3 posttransplant years. Among 21 814 women aged 15-45 years who received a first kidney-only transplant between 1990 and 2010 captured in the United States Renal Data System, n = 729 pregnancies were identified using Medicare claims. The probability of allograft failure from any cause including death (ACGL) at 1, 3, and 5 years after pregnancy was 9.6%, 25.9%, and 36.6%. In multivariate analyses, pregnancy in the first posttransplant year was associated with an increased risk of ACGL (hazard ratio [HR]: 1.18; 95% confidence interval [CI] 1.00, 1.40) and death censored graft loss (DCGL) (HR:1.25; 95% CI 1.04, 1.50), while pregnancy in the second posttransplant year was associated with an increased risk of DCGL (HR: 1.26; 95% CI 1.06, 1.50). Pregnancy in the third posttransplant year was not associated with an increased risk of ACGL or DCGL. These findings demonstrate a higher incidence of allograft failure after pregnancy than previously reported and that the increased risk of allograft failure extends to pregnancies in the second posttransplant year.

Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby

Parenthood is a central focus for women with chronic kidney disease, but raises important fears and uncertainties about risks to their own and their baby’s health. Pregnancy in women with background kidney disease, women receiving dialysis, or those with a functioning kidney transplant poses a challenging clinical scenario, associated with high maternal–fetal morbidity and potential impact on maternal renal health. Improvements in care over recent decades have led to a paradigm shift with cautious optimism and growing interest regarding pregnancies in women with chronic kidney disease. In this review, we discuss obstetric and renal outcomes, and practical aspects of management of pregnancy in this complex cohort.

Pregnancy outcomes following maternal kidney transplantation: a national cohort study

INTRODUCTION

Internal design flaws in previous reports of pregnancies following kidney transplantation have been outlined, and the need for a validation has been stated. The aim of this study was to collect information about obstetrical and neonatal outcomes in all Norwegian pregnancies following maternal kidney transplantation, and to compare these data with the general Norwegian population.

MATERIAL AND METHODS

A retrospective cohort study based on 1 272 000 deliveries in Norway between 1969 and 2013. All data were collected from medical records. From the source population, we compared 119 first deliveries in kidney transplanted women with 238 first deliveries in nontransplanted women. An explanatory strategy was used in the analysis.

RESULTS

The risk of preeclampsia was significantly increased in kidney-transplanted women compared with nontransplanted women (adjusted incidence rate ratio: 6.06, 95% confidence interval 3.18-11.55). Additionally, preeclampsia in kidney-transplanted women was early onset (diagnosed <34 gestational weeks) in half of the cases. There were also persistent risks of cesarean delivery (adjusted incidence rate ratio 4.14, 95% confidence interval 2.56-6.66), preterm delivery (adjusted incidence rate ratio 4.45, 95% confidence interval 2.13-9.30) and a birthweight below the 10th centile (22.7% vs. 9.7%) in the kidney-transplanted group. A high proportion (63%) of the kidney-transplanted women with chronic hypertension developed preeclampsia.

CONCLUSIONS

Using consistent diagnostic criteria, this study shows high rates of maternal and neonatal complications in pregnancies following kidney transplantation. In particular, we reveal a high rate of early-onset preeclampsia requiring operative preterm delivery, conferring long-term risks on both the mother and child.

Pregnancy in Women With CKD: A Success Story

In women with chronic kidney disease (CKD), pregnancy outcomes have improved over the last 50 years, particularly in the developed world. Maternal mortality is now extremely low, fetal survival has markedly increased (even in women with CKD stages 4-5), and it is now the exception for women with CKD to be advised against embarking on a pregnancy. However, pregnancies are rarely free from complications, and there are unanswered questions about the longer term effects on maternal and infant health. The developments have led to a more optimistic attitude to pregnancy in women with CKD not requiring renal replacement treatment. The remaining problems are described in this World Kidney Forum.

Long-Term Functional Recovery, Quality of Life, and Pregnancy After Solid Organ Transplantation

This article reviews the salient features of functional recovery, health-related quality of life (HR-QOL), and reproductive health, with special emphasis on pregnancy outcomes in kidney and liver recipients. Transplantation results in improved functional status and HR-QOL. Addressing factors that limit the optimal rehabilitation of transplant recipients can improve transplant outcomes. After successful transplantation, there is a rapid return of fertility, warranting counseling regarding contraception. Practitioners should be aware of the teratogenic potential of mycophenolic acid products. Posttransplant pregnancies are high risk, with increased incidences of hypertension, preeclampsia, and prematurity. Most pregnancies in kidney and liver recipients have successful maternal and newborn outcomes.

Obstetric and long-term kidney outcomes in renal transplant recipients: a 40-yr single-center study

Female renal transplant recipients of childbearing age may ask what the outcomes are for pregnancy and whether pregnancy will affect graft function. We analyzed obstetric and transplant outcomes among renal transplant recipients in our center who have been pregnant between 1973 and 2013. A case-cohort study was performed identifying 83 pairs of pregnant and non-pregnant controls matched for sex, age, transplant vintage, and creatinine. There were 138 pregnancies reported from 89 renal transplant recipients. There were live births in 74% of pregnancies with high prevalence of prematurity (61%), low birth weight (52%), and pre-eclampsia (14%). Lower eGFR (OR 0.98; p = 0.05) and higher uPCR (OR 1.86; p = 0.02) at conception were independent predictors for poor composite obstetric outcome. Lower eGFR (OR 0.98; p = 0.04), higher uPCR (OR 1.50; p = 0.04), and live organ donation (OR 0.35; p = 0.02) were predictors of ≥20% loss of eGFR between immediately pre-pregnancy and one yr after delivery. There was no difference in eGFR at one, five, and 10 yr in pregnant women compared with non-pregnant controls and a pregnancy was not associated with poorer 10-yr transplant or 20-yr patient survival. Despite high rates of obstetric complications, most women had successful pregnancies with good long-term transplant function.

Contraception After Kidney Transplantation, From Myth to Reality: A Comprehensive Review of the Current Evidence

There is a misconception among transplant clinicians that contraception after a successful renal transplant is challenging. This is partly due to the complex nature of transplant patients, where immunosuppression and graft dysfunction create major concerns. In addition, good evidence regarding contraception and transplant is scarce, with most of the evidence extrapolated from observational and case-controlled studies, thus adding to the dilemma of treating these patients. In this review, we closely analyzed the different methods of contraception and critically evaluated the efficacy of the different options for contraception after kidney transplant. We conclude that contraception after renal transplant is successful with acceptable risk. A multidisciplinary team approach involving obstetricians and transplant clinicians to decide the appropriate timing for conception is recommended. Early counseling on contraception is important to reduce the risk of unplanned pregnancies, improve pregnancy outcomes, and reduce maternal complications in patients after kidney transplant. To ascertain appropriate advice on the method of contraception, individualizing the method of contraception according to a patient's individual risks and expectations is essential.

Pregnancy across the spectrum of chronic kidney disease

Management of the pregnant woman with chronic kidney disease is difficult for both nephrologists and obstetricians. Prepregnancy counselling with respect to risk stratification, optimization of maternal health prior to pregnancy, as well as management of the many potential pregnancy-associated complications in this complex patient population remains challenging due to the paucity of large, well-designed clinical studies. Furthermore, the heterogeneity of disease and the relative infrequency of pregnancy, particularly in more advanced stages of chronic kidney disease, leaves many clinicians feeling ill prepared to manage these pregnancies. As such, counselling is imprecise and management varies substantially across centers. All pregnancies in women with chronic kidney disease can benefit from a collaborative multidisciplinary approach with a team that consists of nephrologists experienced in the management of kidney disease in pregnancy, maternal-fetal medicine specialists, high-risk pregnancy nursing staff, dieticians, and pharmacists. Further access to skilled neonatologists and neonatal intensive care unit support is essential given the risks for preterm delivery in this patient population. The goal of this paper is to highlight some of the data that currently exist in the literature, provide management strategies for the practicing nephrologist at all stages of chronic kidney disease, and explore some of the knowledge gaps where future multinational collaborative research efforts should concentrate to improve pregnancy outcomes in women with kidney disease across the globe.

Pregnancy in a renal transplant recipient with HIV-1 infection: a case report

We report the first case of a pregnancy in a renal transplant recipient with HIV infection. She underwent renal transplantation in 2005 and became pregnant in 2009. The patient underwent vaginal delivery and a healthy full-term, female baby was born. Almost 6 years after delivery, both mother and child were doing well. The management of concurrent renal transplantation, HIV infection and pregnancy was extremely challenging. Women with HIV infection who have undergone renal transplantation should be accurately informed of the potential health risks for them and their offspring. Multidisciplinary teams are mandatory in order to properly manage these patients.

Immunosuppressive drugs and fertility

Immunosuppressive drugs are used in the treatment of inflammatory and autoimmune diseases, as well as in transplantation. Frequently prescribed in young people, these treatments may have deleterious effects on fertility, pregnancy outcomes and the unborn child. This review aims to summarize the main gonadal side effects of immunosuppressants, to detail the effects on fertility and pregnancy of each class of drug, and to provide recommendations on the management of patients who are seen prior to starting or who are already receiving immunosuppressive treatment, allowing them in due course to bear children. The recommendations for use are established with a rather low level of proof, which needs to be taken into account in the patient management. Methotrexate, mycophenolate, and le- and teri-flunomide, cyclophosphamide, mitoxanthrone are contraindicated if pregnancy is desired due to their teratogenic effects, as well as gonadotoxic effects in the case of cyclophosphamide. Anti-TNF-alpha and mTOR-inhibitors are to be used cautiously if pregnancy is desired, since experience using these drugs is still relatively scarce. Azathioprine, glucocorticoids, mesalazine, anticalcineurins such as cyclosporine and tacrolimus, ß-interferon, glatiramer-acetate and chloroquine can be used during pregnancy, bearing in mind however that side effects may still occur. Experience is limited concerning natalizumab, fingolimod, dimethyl-fumarate and induction treatments. Conclusion: At the time of prescription, patients must be informed of the possible consequences of immunosuppressants on fertility and of the need for contraception. Pregnancy must be planned and the treatment modified if necessary in a pre-conception time period adapted to the half-life of the drug, imperatively in relation with the prescriber of the immunosuppressive drugs.

Contraception in women after organ transplantation

INTRODUCTION

Organ transplantation has improved the quality and length of life for many people suffering from end-stage diseases, among them women of reproductive age. Therefore, it has made pregnancy possible for those previously unable to conceive. Nevertheless, conception itself should be desired and properly timed in these specific patients to ensure the best possible perinatal outcome.

OBJECTIVE

The objective of the study was to assess whether female graft recipients apply proper family planning methods and use effective contraception.

METHODS

In a single-center, observational study, information was collected using a self-administered questionnaire distributed among 100 female graft recipients (post-transplant group [TG]) and 67 healthy female volunteers (control group [CG]). The survey covered data regarding present menstrual patterns, sexual activity, gynecological counseling, and contraceptive methods used.

RESULTS

Female graft recipients were more sexually active after than before transplantation (87% vs 64%, P = .0001) and equally active as controls. Sexually active post-transplantation patients used contraception less frequently than sexually active controls (51.72% vs 82.76%, P < .0001). Condoms were the most frequently used method in TG, and oral contraception in CG. Oral contraception was used more rarely by counseled graft recipients than by counseled controls (3.9% vs 60.7%, P < .0001). After counseling, intrauterine device usage increased and oral contraception usage decreased in TG. Among women with chronic diseases, intrauterine device was used more often in TG (4% vs 0%), whereas oral contraception was used more often in CG (8.3% vs 50%, P < .0001).

CONCLUSIONS

Despite the fact that post-transplantation women of reproductive age have many indications for highly effective contraception, only few of them actually use it. Contraceptive counseling has to be included as part of routine post-transplantation care by all health professionals involved in the management of female graft recipients of reproductive age.

Primary Care of the Solid Organ Transplant Recipient

Solid organ transplantation (SOT) is one of the major advances in medicine. Care of the SOT recipient is complex and continued partnership with the transplant specialist is essential to manage and treat complications and maintain health. The increased longevity of SOT recipients will lead to their being an evolving part of primary care practice, with ever more opportunities for care, education, and research of this rewarding patient population. This review discusses the overall primary care management of adult SOT recipients.

Obstetric and neonatal outcome of pregnancies fathered by males on immunosuppression after solid organ transplantation

Immunosuppressive drugs may influence spermatogenesis, but little is known about outcome of pregnancies fathered by transplanted males. We estimated risk of adverse outcomes in pregnancies (with data after the first trimester) fathered by males that had undergone organ transplantation and were treated with immunosuppression. A population-based study, linking data from the Norwegian transplant registry and the Medical Birth Registry of Norway during 1967-2009 was designed. All Norwegian men undergoing solid organ transplantation were included. Odds ratios for major malformations, preeclampsia, preterm delivery (<37 weeks) and small-for-gestational-age were obtained using logistic regression. A total of 2463 transplanted males, fathering babies of 4614 deliveries before and 474 deliveries after transplantation were identified. The risk of preeclampsia was increased (AOR: 7.4, 95% CI: 1.1-51.4,) after transplantation compared to prior to transplantation. No increased risk was found for congenital malformations or other outcomes when compared with pregnancies before transplantation or with the general population (2 511 506 births). Our results indicate an increased risk of preeclampsia mediated through the transplanted and immunosuppressed father. Importantly, no increased risk was found for other adverse obstetric outcomes or malformations, which may reassure male transplant recipients planning to father children.

Immunophenotypic profile and increased risk of hospital admission for infection in infants born to female kidney transplant recipients

Children born to female kidney recipients are exposed to immunosuppressive drugs during gestation. Little is known about their immune system at birth or in the long term. Twenty-eight children born to female kidney recipients and 40 full-term children born to healthy mothers were evaluated. T, B, NK, NKT, γδT cells were assessed by flow cytometry and functional evaluation of T and dendritic cells after in vitro activation was performed at birth and at 8 months of age. At birth, infants born to female kidney recipients showed lower numbers of CD4+ T, NKT and intense reduction of B cells (median cells/mm(3) , transplant: 153.7 X control: 512.4; p < 0.001). There was also a reduced percentage of activated CD8+ T and of CD4+ regulatory T cells. Activated memory and exhausted memory B cells showed higher percentages among children exposed to immunosuppressors when compared to control group. At 8 months, most immune alterations were no longer observed, but four children still had low numbers of some lymphocyte subsets at this age. Children born to female kidney recipients had 4.351 (95% CI: 1.026-15.225; p = 0.046) higher risk of hospital admission in the first months of life-some, with severe clinical manifestations-than those born to healthy women.

Risk of Adverse Pregnancy Outcomes in Women with CKD

CKD is increasingly prevalent in pregnancy. In the Torino-Cagliari Observational Study (TOCOS), we assessed whether the risk for adverse pregnancy outcomes is associated with CKD by comparing pregnancy outcomes of 504 pregnancies in women with CKD to outcomes of 836 low-risk pregnancies in women without CKD. The presence of hypertension, proteinuria (>1 g/d), systemic disease, and CKD stage (at referral) were assessed at baseline. The following outcomes were studied: cesarean section, preterm delivery, and early preterm delivery; small for gestational age (SGA); need for neonatal intensive care unit (NICU); new onset of hypertension; new onset/doubling of proteinuria; CKD stage shift; "general" combined outcome (preterm delivery, NICU, SGA); and "severe" combined outcome (early preterm delivery, NICU, SGA). The risk for adverse outcomes increased across stages (for stage 1 versus stages 4-5: "general" combined outcome, 34.1% versus 90.0%; "severe" combined outcome, 21.4% versus 80.0%; P<0.001). In women with stage 1 CKD, preterm delivery was associated with baseline hypertension (odds ratio [OR], 3.42; 95% confidence interval [95% CI], 1.87 to 6.21), systemic disease (OR, 3.13; 95% CI, 1.51 to 6.50), and proteinuria (OR, 3.69; 95% CI, 1.63 to 8.36). However, stage 1 CKD remained associated with adverse pregnancy outcomes (general combined outcome) in women without baseline hypertension, proteinuria, or systemic disease (OR, 1.88; 95% CI, 1.27 to 2.79). The risk of intrauterine death did not differ between patients and controls. Findings from this prospective study suggest a "baseline risk" for adverse pregnancy-related outcomes linked to CKD.

Cystinosis in adult and adolescent patients: Recommendations for the comprehensive care of cystinosis

INTRODUCTION

Cystinosis is a rare lysosomal systemic disease that mainly affects the kidney and the eye. Patients with cystinosis begin renal replacement therapy during the first decade of life in absence of treatment. Prognosis of cystinosis depends on early diagnosis, and prompt starting and good compliance with cysteamine treatment. Kidney disease progression, extra-renal complications and shorter life expectancy are more pronounced in those patients that do not follow treatment. The objective of this work was to elaborate recommendations for the comprehensive care of cystinosis and the facilitation of patient transition from paediatric to adult treatment, based on clinical experience. The goal is to reduce the impact of the disease, and to improve patient quality of life and prognosis.

METHODS

Bibliographic research and consensus meetings among a multidisciplinary professional team of experts in the clinical practice, with cystinotic patients (T-CiS.bcn group) from 5 hospitals located in Barcelona.

RESULTS

This document gathers specific recommendations for diagnosis, treatment and multidisciplinary follow-up of cystinotic patients in the following areas: nephrology, dialysis,renal transplant, ophthalmology, endocrinology, neurology, laboratory, genetic counselling,nursing and pharmacy.

CONCLUSIONS

A reference document for the comprehensive care of cystinosis represents a support tool for health professionals who take care of these patients. It is based on the following main pillars: (a) a multi-disciplinary approach, (b) appropriate disease monitoring and control of intracellular cystine levels in leukocytes, (c) the importance of adherence to treatment with cysteamine, and (d) the promotion of patient self-care by means of disease education programmes. All these recommendations will lead us, in a second phase, to create a coordinated transition model between paediatric and adult care services which will contemplate the specific needs of cystinosis.