Is immunosuppression therapy in renal allograft recipients teratogenic? A single-center experience

Immunosuppression in uterus transplantation: from transplant to delivery

INTRODUCTION

Uterus transplantation introduces unique challenges regarding immunosuppression, including the effects of immunosuppressive drugs on the fetus and graft rejection during pregnancy. Although immunosuppressive regimens are based on protocols used after solid organ transplantation, in recipients of uterus grafts, the physician must consider therapy modifications based on the phase of the transplant, from the intra-operative period through to delivery.

AREAS COVERED

This review discusses the current immunosuppressive rationale in uterus transplantation, focusing on the therapy in each phase of the transplant. The authors present an overview of the already approved immunosuppressive medications for solid organ transplantation, their application in uterus transplant prior to pregnancy, during pregnancy and as rejection treatment.

EXPERT OPINION

Most medications used for uterus transplant are adopted from solid organ transplantation experience, especially kidney transplantation, and rejection is treated in standard fashion. Research is needed to clarify the drugs' effects on fetal and neonatal well-being and to develop new medications to achieve better tolerance. Early markers of uterus graft rejection need to be identified, and prior rejection episodes should no longer be a cause to remove the graft during delivery in a recipient who wants a further pregnancy.

Follow-Up of Offspring Born to Parents With a Solid Organ Transplantation: A Systematic Review

Pregnancy after solid organ transplantation (SOT) has potential risks for the offspring. Most existing research focused on short-term pregnancy outcomes. The aim of this systematic review was to evaluate available data concerning longer term outcomes (>1 year) of these children. A systematic literature search, following PRISMA guidelines, of PubMed and Embase was performed from the earliest date of inception through to 6th April 2022. Publications on all types of (combined) SOT were eligible for inclusion. In total, 53 articles were included. The majority assessed offspring after kidney (78% of offspring) or liver transplantation (17% of offspring). 33 studies included offspring aged >4 years and five offspring aged >18 years. One study was included on fathers with SOT. The majority of the 1,664 included children after maternal SOT had normal intellectual, psychomotor, and behavioral development. Although prematurity and low birth weight were commonly present, regular growth after 1 year of age was described. No studies reported opportunistic or chronic infections or abnormal response to vaccinations. In general, pregnancy after SOT appears to have reassuring longer term outcomes for the offspring. However, existing information is predominantly limited to studies with young children. Longer prospective studies with follow-up into adulthood of these children are warranted.

Induction of mucosal healing by intensive granulocyte/monocyte adsorptive apheresis (GMA) without use of corticosteroids in patients with ulcerative colitis: long-term remission maintenance after induction by GMA and efficacy of GMA re-treatment upon relapse

This study examined the long-term maintenance rate after inducing remission by intensive granulocyte/monocyte adsorptive apheresis (GMA) without use of corticosteroids (CS) and GMA re-treatment efficacy in the same patients upon relapse with ulcerative colitis. Patients who achieved clinical remission and mucosal healing (MH) by first-time intensive GMA (first GMA) without CS were enrolled. The cumulative non-relapse survival rate up to week 156 was calculated. Patients with relapse during the maintenance period underwent second-time intensive GMA (second GMA) without CS. Clinical remission and MH rates following second GMA were compared to those following first GMA in the same patients. Of the 84 patients enrolled, 78 were followed until week 156 and 34 demonstrated relapse. The cumulative non-relapse survival rate by week 156 was 56.4%. Clinical remission and MH rates after second GMA did not differ from those after first GMA in the same patients (week 6: clinical remission, 100% vs 88.4%, p = 0.134; MH, 100% vs 84.8%, p = 0.074). In conclusion, MH induction by intensive GMA without use of CS in ulcerative colitis patients contributes to subsequent long-term clinical remission maintenance. GMA re-treatment efficacy was comparable to that of first GMA in the same patients who had relapse.

Update in immunosuppressive therapy of myasthenia gravis

Myasthenia gravis (MG) is an autoimmune disease of the neuromuscular junction. Immunosuppressive treatments are part of the therapeutic armamentarium in MG. Long-term systemic steroid administration carry considerable risks and adverse events. Consequently, steroid-free immunosuppressive therapy is necessary to reduce the dose or discontinue steroids. First immunosuppressive drug trials in MG were performed in the mid-60s using standard and nonspecific immunosuppression. Since then, only few randomized controlled clinical trials were conducted in MG and assesed drug efficacy in terms of its steroid-sparing capacity and the ability to reduce myasthenic signs and symptoms. Treatment strategy in MG is quite challenging, mainly due to the disease heterogeneity in terms of clinical presentation, immunopathogenesis and drug response. To solve this dilemma, emerging treatment are based on biological drugs and use new targets of the immune pathway.

In utero exposure to Azathioprine in autoimmune disease. Where do we stand?

Azathioprine (AZA), an oral immunosuppressant, is safe during pregnancy. Some reports suggested different impairments in the offspring of mothers with autoimmune diseases (AI) exposed in utero to AZA. These observations are available from retrospective studies or case reports. However, data with respect to the long-term safety in the antenatally exposed child are still lacking. The aim of this study is to summarize the current knowledge in this field and to focus on the need for a prospective study on this population. We performed a PubMed search using several search terms. The actual data show that although the risk of congenital anomalies in offspring, as well as the infertility risk, are similar to those found in general population, there is a higher incidence of prematurity, of lower weight at birth and an intra-uterine delay of development. There is also an increased risk of materno- fetal infections, especially cytomegalovirus infection. Some authors raise the interrogations about neurocognitive impairment. Even though the adverse outcomes might well be a consequence of maternal illness and disease activity, interest has been raised about a contribution of this drug. However, the interferences between the external agent (in utero exposure to AZA), with the host (child genetic susceptibility, immune system anomalies, emotional status), environment (public health, social context, availability of health care), economic, social, and behavioral conditions, cultural patterns, are complex and represent confounding factors. In conclusion, it is necessary to perform studies on the medium and long-term outcome of children born by mothers with autoimmune diseases, treated with AZA, in order to show the safety of AZA exposure. Only large-scale population studies with long-term follow-up will allow to formally conclude in this field. TAKE HOME MESSAGES.

Successful Pregnancy Outcome in a Recipient With Simultaneous Kidney and Pancreas Transplant Who Underwent Posttransplant Metabolic Surgery

Although chronic kidney disease decreases fertility, kidney transplantation provides restoration of fertility in women, enabling them to get pregnant. Data available from registries have shown that pregnancy is feasible in solid-organ transplant recipients without significant impact on long-term graft function. Despite these reassuring data, some studies have reported that one-third of female transplant recipients are still actively being counseled against pregnancy. Here, we present a patient who received a simultaneous deceased-donor kidney and pancreas transplant and who had a favorably evolved pregnancy. The 36-yearold kidney-pancreas transplant recipient conceived 5 months after her marriage. The patient was closely followed during pregnancy by a multidisciplinary team that included a nephrologist, gynecologist, and endocrinologist. Renal function and blood glucose levels remained within normal limits. She delivered her baby normally at 31 weeks of pregnancy (1.3-kg male baby). Currently, both mother and baby are doing well. Pregnancy in combined kidney and pancreas transplant recipients with stable graft functions is feasible but remains risky. Proper planning, modification of immunosuppressive drugs, and close monitoring are the keys to optimized maternal, fetal, and graft outcomes.

Important problems in the diagnosis and treatment of autoimmune hepatitis (based on the Russian consensus 2017)

The analysis of publications devoted to the Russian Consensus on the Diagnostic and Treatment of Autoimmune Hepatitis (AIH), which was considered at the 43rd annual Scientific Session of the CNIIG From Traditions to Innovation (March 4, 2017) is carried out. The presence of clear algorithms and recommendations for the diagnosis and treatment of AIH significantly help the doctor in real clinical practice, but do not exclude a personified approach to the patient.

Kidney transplantation during a twin pregnancy. Case report and review of the literature

Kidney transplant in a pregnant woman is exceptional, with only six cases being reported. Pregnancy was not known at the time of the transplant in five of these cases. We report the case of a 26-year-old woman who was diagnosed as carrying a twin pregnancy 4 months after starting hemodialysis. In order to improve the survival chances for the twins, she underwent an orthotopic renal transplant from a living donor at 20 weeks of gestation. The allograft functioned immediately and 4 weeks passed without incident. At the 26th week of gestation, the patient had a precipitous labor, delivering two male babies with no malformations, weighing 755 and 890 g, who died due to respiratory failure. The allograft worked normally afterwards. Sixteen months later, the patient delivered a normal 37 weeks' gestation baby. The renal graft continued working normally for the next 20 years, after which signs of chronic allograft nephropathy developed. Azathioprine was replaced with mycophenolate mofetil. At the last evaluation, 23 years after transplant, the patient's serum creatinine was 2.9 mg/dl and her estimated glomerular filtration rate (eGFR) was 22 ml/min/1.73 m². This unique case demonstrates that it is possible to perform an orthotopic kidney transplant in a 20-week twin-gestation, with a long graft survival time.

Immunology of uterine transplantation: a review

The idea of using organ transplantation to solve quality-of-life issues was first introduced a century ago, with cornea transplants and thrusted before the world again in 1998, following a controversial hand transplant. Uterus transplantation (UTn) has been proposed as another quality-of-life transplant for the cure of permanent uterine factor infertility. In order to proceed in humans, a greater appreciation of the immunological mechanisms that underlie UTn is desirable. Allogeneic UTn (animal model) was first described by 2 studies in 1969. The first and only human UTn, performed in 2000, was an early attempt with limited use of animal model experiments prior to moving onto the human setting. Since then, work using rat, mouse, ovine, goat, and nonhuman primate models has demonstrated that the uterus is a very different but manageable organ immunologically compared to other transplanted organs. Therefore, specifically exploring immunological issues relating to UTn is a valuable and necessary part of the inevitable scientific process leading to successful human UTn.

[Dermatologic therapy in pregnancy]

Pharmacologic therapy of a pregnant patient requires particular care in selecting the active substances to be used, their dosage and administration. The teratogenic risk and the therapeutic benefit must be carefully weighed for the mother and possibly also for the child, and attention paid to the special precautions and documentation obligations of off-label applications. This article addresses the general aspects of benefit-risk evaluation, provides an opinion on the teratogenic potency of dermatologically relevant medications, formulates recommendations for frequent general dermatological indications and lists additional possible information sources for special case constellations.

Outcomes of pregnancies fathered by inflammatory bowel disease patients exposed to thiopurines

OBJECTIVES

Immunomodulators are used as maintenance treatment of inflammatory bowel disease (IBD). Data regarding their possible effects in the course of pregnancy when the father is exposed at the time of conception are limited.

METHODS

To evaluate the outcomes of pregnancies of which the fathers were exposed to thiopurines at the time of conception. A series of male patients followed in seven IBD clinics in Madrid, Spain, was studied. Any exposure to thiopurines during the 3 months preceding conception was considered significant. Controls were pregnancies fathered by patients who either had never been treated with thiopurines or had interrupted them >3 months before conception. Statistical comparisons and multivariate analysis were carried out with the generalized estimating equations model.

RESULTS

There were 46 conceptions in the exposed group (mercaptopurine 9, azathioprine 37) and 84 in the control group. In the exposed group, there were more Crohn's patients (82.6% vs. 53.6%), the duration of the disease was longer (median: 8 vs. 5 years), fathers were slightly older (mean: 34.2 vs. 32.7 years), and there were fewer patients on mesalamine (15.2% vs. 47.6%). Otherwise, baseline characteristics were similar in both groups. There were no significant differences regarding unsuccessful pregnancies-namely, spontaneous abortions, ectopic pregnancies, anembryonic pregnancies, or fetal deaths (10.9% exposed group vs. 13.1% control group; odds ratio (OR): 0.79, confidence interval (CI): 0.22-2.85), preterm births (4.3% vs. 2.4%; OR: 1.3, CI: 0.22-7.61), low birth weight (6.5% vs. 6%; OR: 1.06, CI: 0.25-4.54), or congenital malformations (2.2% vs. 2.4%; OR: 0.82, CI: 0.08-9). No infant neoplasms were detected. The proportion of conceptions that needed >1 year to be achieved was higher in the exposed group, but this was not statistically significant (15.2% vs. 8.3%; OR: 1.92, CI: 0.54-6.88). Multivariate analysis was carried out for unsuccessful pregnancies and fertility impairment, and it showed that, although mesalamine exposure confounded the effect of the exposure to thiopurines on these outcomes, this effect was still nonsignificant (respectively, OR: 0.49, CI: 0.17-1.44; OR: 2.82, CI: 0.7-11.38).

CONCLUSIONS

Our data do not support the practice of routinely recommending to male patients that they interrupt thiopurines when wanting to conceive.

Immune thrombocytopenia in pregnancy

Management of immune thrombocytopenia in pregnancy can be a complex and challenging task and may be complicated by fetal-neonatal thrombocytopenia. Although fetal intracranial hemorrhage is a rare complication of immune thrombocytopenia in pregnancy, invasive studies designed to determine the fetal platelet count before delivery are associated with greater risk than that of fetal intracranial hemorrhage and are discouraged. Moreover, the risk of neonatal bleeding complications does not correlate with the mode of delivery, and cesarean section should be reserved only for obstetric indications.

Early pregnancy azathioprine use and pregnancy outcomes

BACKGROUND

Azathioprine (AZA) is used during pregnancy by women with inflammatory bowel disease (IBD), other autoimmune disorders, malignancy, and organ transplantation. Previous studies have demonstrated potential risks.

METHODS

The Swedish Medical Birth Register was used to identify 476 women who reported the use of AZA in early pregnancy. The effect of AZA exposure on pregnancy outcomes was studied after adjustment for maternal characteristics that could act as confounders.

RESULTS

The most common indication for AZA use was IBD. The rate of congenital malformations was 6.2% in the AZA group and 4.7% among all infants born (adjusted OR: 1.41, 95% CI: 0.98-2.04). An association between early pregnancy AZA exposure and ventricular/atrial septal defects was found (adjusted OR: 3.18, 95% CI: 1.45-6.04). Exposed infants were also more likely to be preterm, to weigh <2500 gm, and to be small for gestational age compared to all infants born. This effect remained for preterm birth and low birth weight when infants of women with IBD but without AZA exposure were used as a comparison group. A trend toward an increased risk of congenital malformations was found among infants of women with IBD using AZA compared to women with IBD not using AZA (adjusted OR: 1.42, 95% CI: 0.93-2.18).

CONCLUSIONS

Infants exposed to AZA in early pregnancy may be at a moderately increased risk of congenital malformations, specifically ventricular/atrial septal defects. There is also an increased risk of growth restriction and preterm delivery. These associations may be confounded by the severity of maternal illness.

Management of immune thrombocytopenic purpura in pregnancy

Chronic immune thrombocytopenic purpura (ITP) is an autoimmune disease characterized by a low platelet count and mucocutaneous bleeding. Pregnancy does not increase the incidence of ITP nor does it exacerbate a preexisting disease. Although pregnant women with ITP may experience several maternal and fetal complications, in most cases even with a very low platelet count, there is neither maternal nor fetal morbidity or mortality. Corticosteroids are the first line of therapy in pregnant women; intravenous immune globulin is commonly used in steroid resistant patients. Other treatments such as intravenously administered anti-D (Rhogam) and splenectomy during pregnancy have been reported. Antiplatelet IgG antibodies can cross the placenta and can induce fetal thrombocytopenia. In most women there is no indication to assess fetal platelet counts during the pregnancy. The mode of delivery is determined by obstetrical considerations.

Fertility Following Solid Organ Transplantation

Fertility is usually restored in women after solid organ transplantation, and successful pregnancies have been reported in female recipients of kidney, liver, heart, pancreas-liver, and lung transplants. However, women with solid organ allografts have higher incidence of pregnancy complications like hypertension, preeclampsia, preterm delivery. Hypertension appears to be dependent on the type of immunosuppressive agents. The influence of pregnancy on the risk of rejection is poorly known on the basis of available data. Rejection rate appears to be at least similar to the nonpregnant population. In some cases, such as in liver transplant pregnant women, even higher as compared to the nonpregnant population. Maintaining appropriate blood levels of immunosuppressive drugs is currently recommended. Malformation rate in the offsprings of transplanted women appears to not be increased; long-term follow- up of children born to allograft recipients is necessary to investigate possible developmental, immunological, or oncological disorders. We followed 70 pregnancies after kidney transplantation and nine after liver transplantation. All recipients were maintained on immunosuppressive therapy during pregnancy, except one mother who refused immunosuppression and experienced transplant rejection. Hypertension was the most frequent complication during pregnancy: in 23% of kidney transplantated mothers and in one out of nine liver transplant recipients. The only malformation observed in the newborns was the dislocation of the hip in the child of a kidney transplant recipient.

Birth outcome in women treated with azathioprine or mercaptopurine during pregnancy: A Danish nationwide cohort study

BACKGROUND

Data on birth outcome after exposure to azathioprine or mercaptopurine during pregnancy is sparse.

AIM

To examine the risk of adverse birth outcome among newborns of women exposed to azathioprine or mercaptopurine during pregnancy.

METHODS

Data on drug use and births were obtained from Danish population registries. We included 76 exposed pregnancies in 69 women. Of these, we used 64 pregnancies exposed 30 days before conception or during the first trimester to examine the risk of congenital abnormalities, and 65 pregnancies exposed during the entire pregnancy to examine preterm birth and low birth weight at term. Their birth outcomes were compared with outcomes among women who did not fill prescriptions for azathioprine or mercaptopurine during pregnancy.

RESULTS

Azathioprine- or mercaptopurine-exposed women had a higher risk of adverse birth outcomes than unexposed controls. However, when the comparison was limited to newborns of women with the same types of underlying disease, relative risks for spontaneous and induced preterm birth, low birth weight at term, and congenital abnormalities were 1.1 (95% CI: 0.5-2.4), 4.0 (95% CI: 1.5-10.8), 1.7 (95% CI: 0.3-8.7) and 1.1 (95% CI: 0.5-2.9), respectively.

CONCLUSION

Our results suggest that adverse birth outcomes were caused by the underlying disease rather than by use of azathioprine or mercaptopurine.

Pregnancy in Renal Transplant Recipients: Long-Term Effect on Patient and Graft Survival. A Single-Center Experience

BACKGROUND

There are limited data on the effect of pregnancy on long-term renal allograft function. The aim of the study was to compare long-term graft and patient outcome between pregnant and nonpregnant women after renal transplantation.

METHODS

The study group consisted of 39 women attending the Perinatal Division of the Rabin Medical Center who conceived after undergoing renal transplantation (total number of live births: 55). All had a functioning allograft at the time of conception. Each patient was matched with 3 controls for 12 factors known to affect graft survival. The controls were derived from a cohort of 250,000 transplant patients registered in the Collaborative Transplantation Study (CTS) database. The groups were compared for graft survival, long-term patient survival, and kidney function (CTS clinical grading scale).

RESULTS

Graft (61.6%) and patient (84.8 %) survival from transplantation to the end of follow-up (15 years) in the women who conceived after transplantation did not differ from the rates observed in the 177 women in the matched control group (68.7% and 78.8 %, respectively). There were no between-group differences in long-term graft function.

CONCLUSION

Pregnancy does not appear to have adverse effects on long-term graft or patient survival or kidney function in women after renal transplantation.

Pregnancy in patients with previous successful renal transplantation

OBJECTIVE

To evaluate the risk factors affecting pregnancy, perinatal outcomes, and short-term graft condition in women who underwent renal transplantation.

METHOD

Between May 1998 and January 2005, the histories of 20 pregnancies in 17 renal transplant recipients were reviewed retrospectively at the Ministry of Health Aegean Obstetrics and Gynecology Teaching Hospital.

RESULT

There were significant associations between high serum creatinine level (>1.5 mg/dL) prior to pregnancy and preterm delivery (P=0.04), and between short interval between transplantation and pregnancy (<2 years) and increased rate of cesarean sections (P=0.04). There were no significant changes in serum creatinine levels during pregnancy in these women, and there were no acute rejection and graft loss during pregnancy or in the 6 months following delivery.

CONCLUSION

These findings suggest that, although pregnancy does not adversely affect short-term renal allograft function, the rates of obstetric and perinatal complications are increased. Risk factors present before conception are a short interval between renal transplantation and pregnancy and poor renal function.

Guidelines for prescribing azathioprine in dermatology

Azathioprine has been available as an immunosuppressive agent for over 40 years, and current routine usage in dermatology is not restricted to licensed indications. Advances in understanding the metabolic fate of azathioprine have led to significant changes in prescribing practice and toxicity monitoring by U.K. dermatologists. The current state of knowledge concerning the use of azathioprine in dermatology is summarized, with identification of strength of evidence. Clinical indications and contraindications for azathioprine usage in dermatology are identified. Evidence-based recommendations are made for routine safety monitoring of patients treated with azathioprine, including pretreatment assessment of red blood cell thiopurine methyltransferase activity.