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Vinciguerra C, D’Amico A, Bevilacqua L, Rini N, D’Apolito M, Liberatoscioli E, Monastero R, Barone P, Brighina F, Di Muzio A, Di Stefano V. Effectiveness and Safety of Mycophenolate Mophetil in Myasthenia Gravis: A Real-Life Multicenter Experience. Brain Sci 2024; 14:774. [PMID: 39199468 PMCID: PMC11352837 DOI: 10.3390/brainsci14080774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2024] [Revised: 07/27/2024] [Accepted: 07/30/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disease characterized by fluctuating muscle weakness due to autoantibodies targeting neuromuscular junction proteins. Mycophenolate mofetil (MMF), an immunosuppressive therapy, has shown potential for managing MG with fewer side effects compared to other treatments. This study aims to evaluate the effectiveness and safety of MMF in MG patients in a real-life multicenter setting. METHODS A retrospective cohort study was conducted on generalized MG patients, refractory to azathioprine (AZA) and treated with MMF alone or with steroids, at three Italian centers from January 2011 to February 2024. Patients were assessed using the Myasthenia Gravis Foundation of America (MGFA) classification, MG composite score (MGCS), and MG activity of daily living (MGADL) scores at baseline, 6, 12, 18, and 24 months. Statistical analyses included the Spearman correlation, the Friedman test, and ANOVA. RESULTS Thirty-two patients were enrolled (13 males, mean age 66.5 ± 11.5 years). Significant improvements in MGADL and MGCS scores were observed at 6 and 12 months (p < 0.001), with continued improvement over 24 months. Side effects were reported in 12% of patients. MMF showed a faster onset of symptom control compared to azathioprine, with a significant improvement noted within 6 months. CONCLUSIONS A recent study found that MMF and AZA were equally effective in improving patients' quality of life, but because AZA had more serious adverse events than MMF, lower doses of AZA were therefore recommended to reduce the adverse events while maintaining efficacy. Conversely, results showed that MMF is effective and well-tolerated in the long-term management of MG, providing faster symptom control and a favorable safety profile. Future prospective studies with larger cohorts are needed to confirm these findings and explore sex differences in response to MMF treatment.
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Affiliation(s)
- Claudia Vinciguerra
- Neurology Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University Hospital San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
| | - Anna D’Amico
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University of Palermo, 90127 Palermo, Italy (V.D.S.)
| | - Liliana Bevilacqua
- Neurology Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University Hospital San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
| | - Nicasio Rini
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University of Palermo, 90127 Palermo, Italy (V.D.S.)
| | - Maria D’Apolito
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Eliana Liberatoscioli
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Roberto Monastero
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University of Palermo, 90127 Palermo, Italy (V.D.S.)
| | - Paolo Barone
- Neurology Unit, Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University Hospital San Giovanni di Dio e Ruggi D’Aragona, 84131 Salerno, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University of Palermo, 90127 Palermo, Italy (V.D.S.)
| | - Antonio Di Muzio
- Department of Neuroscience, Imaging and Clinical Sciences, “G. d’Annunzio” University, 66100 Chieti, Italy
| | - Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), University of Palermo, 90127 Palermo, Italy (V.D.S.)
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Coscia LA, Kliniewski D, Constantinescu S, Moritz MJ. Pregnancy after transplant in the older adolescent: Anticipatory guidance for the pediatric provider. Pediatr Transplant 2024; 28:e14752. [PMID: 38682682 DOI: 10.1111/petr.14752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Healthcare providers who care for adolescent and young adult transplant recipients should be aware of contraception counseling and potential for pregnancy in this at-risk cohort. METHODS This paper will review contraceptive options in general for transplant recipients. There will also be a review of common immunosuppressive medications and their risk profile regarding pregnancy after transplantation. Data from the Transplant Pregnancy Registry International were analyzed looking at recipients conceiving under the age of 21 and were compared to overall pregnancy outcomes. RESULTS Overall pregnancy outcomes in recipients under the age of 21 are like the adult cohort. CONCLUSION It is imperative to provide contraception counseling to the adolescent and young adult and inform their caregiver that pregnancy can happen if the recipient is sexually active. Pregnant adolescent and young adult transplant recipients should be followed by a multidisciplinary team to assure a positive outcome for the recipient, transplant, and neonate.
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Affiliation(s)
- Lisa A Coscia
- Transplant Pregnancy Registry International, a division of Gift of Life Institute, Philadelphia, Pennsylvania, USA
| | - Dorothy Kliniewski
- Transplant Pregnancy Registry International, a division of Gift of Life Institute, Philadelphia, Pennsylvania, USA
| | - Serban Constantinescu
- Transplant Pregnancy Registry International, a division of Gift of Life Institute, Philadelphia, Pennsylvania, USA
- Department of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Michael J Moritz
- Transplant Pregnancy Registry International, a division of Gift of Life Institute, Philadelphia, Pennsylvania, USA
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Dubucs C, N'Go V, Caillet A, Cifuentes EA, Beau AB, Frémont F, Hurault-Delarue C, Courtade-Saïdi M, Damase-Michel C. The EFEMEREYE Study: prenatal medication exposure and ocular anomaly occurrence in EFEMERIS health database. J AAPOS 2024:103931. [PMID: 38719141 DOI: 10.1016/j.jaapos.2024.103931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/01/2024] [Accepted: 03/07/2024] [Indexed: 05/21/2024]
Abstract
PURPOSE To describe ocular anomalies (OAs) in children and fetuses in a French general population, to estimate their prevalence, and to investigate a possible association between prenatal medication exposure and the occurrence of OA in utero or in early childhood. METHODS We conducted a case-control study using the EFEMERIS cohort, a database containing pregnancies registered in Haute-Garonne and their outcomes. We collected OA descriptions of fetuses at the time of pregnancy termination or of children at birth and the results of eye examinations of children at 9 months and 2 years of age. RESULTS The prevalence of overall OAs was 2.13%, of which 0.04% were congenital ocular malformations (COMs). A total of 2,968 cases and 136,619 controls were selected for analysis. There was a significant difference between the two groups with regard to prenatal exposure to medications for the digestive tract and metabolism, the cardiovascular system, and the respiratory system. Multivariable analysis revealed an increased risk of OA in children of mothers exposed to magnesium during and 1 month before pregnancy (OR = 1.24; 95% CI, 1.11-1.38). CONCLUSIONS This first pharmaco-epidemiological study on OA in France suggests that OA may be associated with exposure to commonly used medications. Given the rarity of COM, larger, international studies are warranted.
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Affiliation(s)
- Charlotte Dubucs
- Département d'Anatomie et cytologie pathologiques, IUCT-Oncopole, Toulouse, France; Unité de Pharmaco-épidémiologie, UMR 1027, équipe SPHERE - Study of Perinatal, paediatric and adolescent Health: Epidemiological Research and Evaluation, Université de Toulouse, Toulouse, France.
| | - Van N'Go
- Unité de Pharmaco-épidémiologie, UMR 1027, équipe SPHERE - Study of Perinatal, paediatric and adolescent Health: Epidemiological Research and Evaluation, Université de Toulouse, Toulouse, France
| | - Anthony Caillet
- Unité de Pharmaco-épidémiologie, UMR 1027, équipe SPHERE - Study of Perinatal, paediatric and adolescent Health: Epidemiological Research and Evaluation, Université de Toulouse, Toulouse, France
| | - Erika-Alejandra Cifuentes
- Unité de Pharmaco-épidémiologie, UMR 1027, équipe SPHERE - Study of Perinatal, paediatric and adolescent Health: Epidemiological Research and Evaluation, Université de Toulouse, Toulouse, France
| | - Anna-Belle Beau
- Unité de Pharmaco-épidémiologie, UMR 1027, équipe SPHERE - Study of Perinatal, paediatric and adolescent Health: Epidemiological Research and Evaluation, Université de Toulouse, Toulouse, France
| | - Félix Frémont
- Clinique Honoré Cave, Montauban, France; Service d'ophtalmologie, Hôpital Pierre-Paul Riquet, CHU Toulouse-Purpan, Toulouse, France
| | - Caroline Hurault-Delarue
- Unité de Pharmaco-épidémiologie, UMR 1027, équipe SPHERE - Study of Perinatal, paediatric and adolescent Health: Epidemiological Research and Evaluation, Université de Toulouse, Toulouse, France
| | | | - Christine Damase-Michel
- Unité de Pharmaco-épidémiologie, UMR 1027, équipe SPHERE - Study of Perinatal, paediatric and adolescent Health: Epidemiological Research and Evaluation, Université de Toulouse, Toulouse, France; Service de pharmacologie, équipe médicament et grossesse, CHU Toulouse, Toulouse, France
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Chakravarty EF, Utset T, Kamen DL, Contreras G, McCune WJ, Aranow C, Kalunian K, Massarotti E, Clowse MEB, Rovin BH, Lim SS, Majithia V, Dall'Era M, Looney RJ, Erkan D, Saxena A, Olsen NJ, Ko K, Guthridge JM, Goldmuntz E, Springer J, D'Aveta C, Keyes-Elstein L, Barry B, Pinckney A, McNamara J, James JA. Mycophenolate mofetil withdrawal in patients with systemic lupus erythematosus: a multicentre, open-label, randomised controlled trial. THE LANCET. RHEUMATOLOGY 2024; 6:e168-e177. [PMID: 38301682 PMCID: PMC10922882 DOI: 10.1016/s2665-9913(23)00320-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/14/2023] [Accepted: 11/20/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Mycophenolate mofetil is an immunosuppressant commonly used to treat systemic lupus erythematosus (SLE) and lupus nephritis. It is a known teratogen associated with significant toxicities, including an increased risk of infections and malignancies. Mycophenolate mofetil withdrawal is desirable once disease quiescence is reached, but the timing of when to do so and whether it provides a benefit has not been well-studied. We aimed to determine the effects of mycophenolate mofetil withdrawal on the risk of clinically significant disease reactivation in patients with quiescent SLE on long-term mycophenolate mofetil therapy. METHODS This multicenter, open-label, randomised trial was conducted in 19 centres in the USA. Eligible patients were aged between 18 and 70 years old, met the American College of Rheumatology (ACR) 1997 SLE criteria, and had a clinical SLEDAI score of less than 4 at screening. Mycophenolate mofetil therapy was required to be stable or decreasing for 2 years or more if initiated for renal indications, or for 1 year or more for non-renal indications. Participants were randomly allocated in a 1:1 ratio to a withdrawal group, who tapered off mycophenolate mofetil over 12 weeks, or a maintenance group who maintained their baseline dose (1-3g per day) for 60 weeks. Adaptive random allocation ensured groups were balanced for study site, renal versus non-renal disease, and baseline mycophenolate mofetil dose (≥2 g per day vs <2 g per day). Clinically significant disease reactivation by week 60 following random allocation, requiring increased doses or new immunosuppressive therapy was the primary endpoint, in the modified intention-to-treat population (all randomly allocated participants who began study-provided mycophenolate mofetil). Non-inferiority was evaluated using an estimation-based approach. The trial was registered at ClinicalTrials.gov (NCT01946880) and is completed. FINDINGS Between Nov 6, 2013, and April 27, 2018, 123 participants were screened, of whom 102 were randomly allocated to the maintenance group (n=50) or the withdrawal group (n=52). Of the 100 participants included in the modified intention-to-treat analysis (49 maintenance, 51 withdrawal), 84 (84%) were women, 16 (16%) were men, 40 (40%) were White, 41 (41%) were Black, and 76 (76%) had a history of lupus nephritis. The average age was 42 (SD 12·7). By week 60, nine (18%) of 51 participants in the withdrawal group had clinically significant disease reactivation, compared to five (10%) of 49 participants in the maintenance group. The risk of clinically significant disease reactivation was 11% (95% CI 5-24) in the maintenance group and 18% (10-32) in the withdrawal group. The estimated increase in the risk of clinically significant disease reactivation with mycophenolate mofetil withdrawal was 7% (one-sided upper 85% confidence limit 15%). Similar rates of adverse events were observed in the maintenance group (45 [90%] of 50 participants) and the withdrawal group (46 [88%] of 52 participants). Infections were more frequent in the mycophenolate mofetil maintenance group (32 [64%]) compared with the withdrawal group (24 [46%]). INTERPRETATIONS Mycophenolate mofetil withdrawal is not significantly inferior to mycophenolate mofetil maintenance. Estimates for the rates of disease reactivation and increases in risk with withdrawal can assist clinicians in making informed decisions on withdrawing mycophenolate mofetil in patients with stable SLE. FUNDING The National Institute of Allergy and Infectious Diseases and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.
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Affiliation(s)
- Eliza F Chakravarty
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Tammy Utset
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Diane L Kamen
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - W Joseph McCune
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Cynthia Aranow
- Autoimmune and Musculoskeletal Disease, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Kenneth Kalunian
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, La Jolla, CA, USA
| | - Elena Massarotti
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Megan E B Clowse
- Division of Rheumatology and Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Brad H Rovin
- Division of Nephrology, Ohio State University, Columbus, OH, USA
| | - S Sam Lim
- School of Medicine, Emory University, Atlanta, GA, USA
| | - Vikas Majithia
- Division of Rheumatology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Maria Dall'Era
- Division of Rheumatology, Russell/Engleman Rheumatology Research Center, University of California, San Francisco, CA, USA
| | - R John Looney
- Allergy Immunology Rheumatology Division, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Amit Saxena
- Division of Rheumatology, Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Nancy J Olsen
- Division of Rheumatology, Department of Medicine, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Kichul Ko
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Joel M Guthridge
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA; Departments of Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Ellen Goldmuntz
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | - Jessica Springer
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | | | | | - Bill Barry
- Rho Federal Systems Division, Durham, NC, USA
| | | | - James McNamara
- Division of Allergy, Immunology, and Transplantation, NIH/NIAID, Bethesda, MD, USA
| | - Judith A James
- Arthritis and Clinical Immunology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA; Departments of Medicine and Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Drljevic-Nielsen A, Heilskov S, Deleuran MS, Vestergaard C. Immunosuppressive and immunomodulating therapy for atopic dermatitis in pregnancy: an appraisal of the literature. Ital J Dermatol Venerol 2024; 159:23-33. [PMID: 38226937 DOI: 10.23736/s2784-8671.23.07692-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Atopic dermatitis (AD) is the most common dermatological diagnosis during pregnancy. Treatment of AD during pregnancy can be challenging, due to the unpredictable course and the fact that the therapy needs to be safe for both the mother and the fetus. Here we present an up-to-date appraisal of the literature on the treatment options available for AD in patients planning pregnancy, during pregnancy, and during breastfeeding. All patients with AD are recommended to supplement any medical treatment with daily applications of emollients. The first step in the medical treatment for AD during pregnancy are topical corticosteroids, and/or topical tacrolimus. If required, UV-light therapy can also be considered. Treatment with systemic therapy during pregnancy should always rely on a careful risk-benefit assessment and be based on shared-decision making between the treating physician and patient. The first-line systemic treatment option is cyclosporine A, whereas azathioprine may be considered in patients already receiving this treatment prior to pregnancy. Systemic glucocorticoids may also be used. Treatment with systemic JAK inhibitors is not recommended, whereas treatment with mycophenolate mofetil and methotrexate is contraindicated. Targeted therapy with dupilumab is not generally recommended, due to lack of experience in human pregnancies, yet some case-reports on their use are emerging. These recommendations are based on the authors appraisal of existing literature and the current recommendation from the European Task Force on Atopic Dermatitis. It is always the responsibility of the treating physician to stay updated on the newest guidelines and literature when treating patients with AD during pregnancy.
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Affiliation(s)
| | - Sofine Heilskov
- Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette S Deleuran
- Department of Dermatology, Aarhus University Hospital, Aarhus, Denmark
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Ting MYL, Vega-Tapia F, Anguita R, Cuitino L, Valenzuela RA, Salgado F, Valenzuela O, Ibañez S, Marchant R, Urzua CA. Non-Infectious Uveitis and Pregnancy, is There an Optimal Treatment? Uveitis Course and Safety of Uveitis Treatment in Pregnancy. Ocul Immunol Inflamm 2024:1-13. [PMID: 38194442 DOI: 10.1080/09273948.2023.2296030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 12/11/2023] [Indexed: 01/11/2024]
Abstract
In pregnancy, a plethora of factors causes changes in maternal immunity. Uveitis flare-ups are more frequent in the first trimester and in undertreated patients. Management of non-infectious uveitis during pregnancy remains understudied. A bibliographic review to consolidate existing evidence was performed by a multidisciplinary group of Ophthalmologists, Gynaecologists and Rheumatologists. Our group recommends initial management with minimum-required doses of corticosteroids, preferably locally, to treat intraocular inflammation whilst ensuring good neonatal outcomes. If ineffective, clinicians should consider addition of Cyclosporine, Azathioprine or Certolizumab pegol, which are seemingly safe in pregnancy. Other therapies (such as Methotrexate, Mycophenolate Mofetil and alkylating agents) are teratogenic or have a detrimental effect on the foetus. Furthermore, careful multidisciplinary preconception discussions and close follow-up are recommended, monitoring for flare-ups and actively tapering medication doses, with a primary endpoint focused on protecting ocular tissues from inflammation, whilst giving minimal risk of poor pregnancy and foetal outcomes.
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Affiliation(s)
| | - Fabian Vega-Tapia
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Rodrigo Anguita
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Loreto Cuitino
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Servicio de Oftalmología, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Rodrigo A Valenzuela
- Department of Health Science, Universidad de Aysén, Coyhaique, Chile
- Department of Chemical and Biological Sciences, Faculty of Health, Universidad Bernardo O'Higgins, Santiago, Chile
| | - Felipe Salgado
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Omar Valenzuela
- Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Sebastian Ibañez
- Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Ruben Marchant
- Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Cristhian A Urzua
- Laboratory of Ocular and Systemic Autoimmune Diseases, Department of Ophthalmology, Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Faculty of Medicine, Clinica Alemana-Universidad del Desarrollo, Santiago, Chile
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7
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Chen Q, Zhang Y, Luo Y, Li G. Mycophenolate mofetil exposure on embryonic and fetal ear development in rats during pregnancy. Birth Defects Res 2023; 115:1411-1423. [PMID: 37602693 DOI: 10.1002/bdr2.2214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/21/2023] [Accepted: 06/16/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND To explore the pathogenesis of microtia, in this study, the different concentrations of mycophenolate mofetil (MMF) exposure on the development of rat embryonic and fetal ears, in order to establish a drug-induced microtia model, and provide a basis for further exploring the pathogenesis of microtia. METHODS The pregnant rat model was established in this study, 56 pregnant SD rats were randomly divided into 4 groups: control group and MMF (50, 100, and 200 mg/kg) group. Solutions were administered to the rats by oral gavage at gestation day (GD) 9 and GD 10 8:00 a.m, once a day. On GD 10.5 and GD 14.5, embryos were evaluated for neural crest development. On GD 20.5, fetuses were evaluated for overall survival and development with particular focus on ear development via morphologic, skeletal, and histologic investigation. Some animals were allowed to deliver their litters and offspring were evaluated on postnatal day 18 for ear development. RESULTS A total of 56 pregnant rats, 14 in each group, were included in the study. As a result, depending on MMF dose increase, in experimental groups, it was determined that the statistically significant the development of the first and second branchial arches and derived tissues of the embryo, overall survival, ear development, and length and weight of fetuses. Imaging of MMF groups revealed statistically significant differences in the development of the skull and auditory vesicles of MMF treated fetuses. Histologically, MMF affected the proliferation and differentiation of chondrocytes and the expression of type II collagen. CONCLUSIONS Mycophenolate mofetil can lead to the hypoplasia of rat embryos, fetuses, and auricle in a dose-dependent. MMF may affect the migration and proliferation of cranial neural crest cells, and then lead to microtia. MMF may induce the establishment of an animal model of microtia.
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Affiliation(s)
- Qian Chen
- Department of Plastic and Cosmetic Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Yang Zhang
- Department of Plastic and Cosmetic Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Youqi Luo
- Department of Plastic and Cosmetic Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
| | - Gaofeng Li
- Department of Plastic and Cosmetic Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, China
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Yenebere P, Doraiswamy M, Gundroo A. Overview of pregnancy in solid-organ transplantation. Curr Opin Organ Transplant 2023; 28:271-278. [PMID: 37219085 DOI: 10.1097/mot.0000000000001075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
PURPOSE OF REVIEW Pregnancy in solid organ transplantation (SOT) is a very complex part of transplant medicine wherein there is scarce information available in the literature. Solid organ transplant recipients often have comorbidities, such as hypertension and diabetes, which add additional risk to a pregnancy. RECENT FINDINGS We present this review article on the various aspects of different types of immunosuppressant medications used in pregnancy with added inputs on contraception and fertility after transplant. We described the antepartum and postpartum considerations and discussed the adverse effects of the immunosuppressive medications. Maternal and fetal complications of each SOT have been also discussed in this article. SUMMARY This article will serve as the primary review articles for the use of immunosuppressive medications during pregnancy with consideration during pregnancy after SOT.
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Affiliation(s)
- Priya Yenebere
- Transplant Nephrology, Department of Internal Medicine, Indiana University, Indianapolis, Indiana
| | - Mohankumar Doraiswamy
- Nephrology - Critical Care, Department of Internal Medicine, Mercy Hospital, Fort Smith, Arkansas
| | - Aijaz Gundroo
- Transplant Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Freus M, Kabat-Koperska J, Frulenko I, Wiszniewska B, Kolasa A. Morphology of the male rat gonad after in Utero exposure to immunosuppressants. Reprod Biol 2023; 23:100757. [PMID: 37011422 DOI: 10.1016/j.repbio.2023.100757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 04/03/2023]
Abstract
The protocol for immunosuppression of pregnant women is based on immunosuppressant panels. The aim of the study was to determine the influence of commonly applied combinations of immunosuppressants to pregnant rats on the morphology of the offspring' testes. Pregnant rats were treated with cyclosporin A (CsA), mycophenolate mofetil (MMF) and prednisone (Pred) (CMG); tacrolimus (Tc), MMF and Pred (TMG); CsA, everolimus (Ev) and Pred (CEG). Testes of mature offspring underwent morphological analysis. Mainly in the testes of CMG and TMG rats the morphological and functional changes were observed: immature germ cells (GCs) in the seminiferous tubule (ST) lumen, invaginations of the basement membrane, infolding to the seminiferous epithelium (SE), the ST wall thickening, increased acidophilia of Sertoli cells' (SCs) cytoplasm, large residual bodies near the lumen, dystrophic ST and tubules look like the Sertoli cell-only syndrome, Leydig cells with abnormal cell nucleus, hypertrophy of the interstitium, blurring of the boundary between ST wall and interstitium, a reduced number of GCs in the SE, vacuolation of the SE. In the CEG there were only a reduced number of GCs in some tubules and vacuolization of SCs. The safest combination of drugs was CEG, while the TMG and CMG were gonadotoxic.
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Habli M, Belal D, Sharma A, Halawa A. Infertility, pregnancy and breastfeeding in kidney transplantation recipients: Key issues. World J Meta-Anal 2023; 11:55-67. [DOI: 10.13105/wjma.v11.i3.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/22/2023] [Accepted: 02/13/2023] [Indexed: 03/01/2023] Open
Abstract
Chronic kidney disease (CKD), especially in advanced stages, is an important cause of infertility. In CKD patients, infertility has been linked to multiple factors. The pathophysiology of infertility related to CKD is complex and forked. Correction of modifiable factors can improve fertility in both genders. In males as well as females, successful kidney transplantation offers good chances of restoration of reproductive function. In female renal allograft recipients, recovery of reproductive functions in the post-transplant period will manifest as restoration of normal menses and ovulation. Owing to this improvement, there is a significant risk of unplanned pregnancy, hence the need to discuss methods of contraception before transplantation. In kidney transplant recipients, different contraceptive options for pregnancy planning, have been used. The selection of one contraception over another is based on preference and tolerability. Pregnancy, in renal transplanted females, is associated with physiologic changes that occur in pregnant women with native kidneys. Immunosuppressive medications during pregnancy, in a recipient with a single functioning kidney, expose the mother and fetus to unwanted complications. Some immunosuppressive drugs are contraindicated during pregnancy. Immunosuppressive medications should be discussed with renal transplant recipients who are planning to breastfeed their babies. In addition to antirejection drugs, other medications should be managed accordingly, whenever pregnancy is planned.
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Affiliation(s)
- Mohamad Habli
- Department of Internal Medicine, Division of Nephrology, Kingdom Hospital, Riyadh 11564, Saudi Arabia
| | - Dawlat Belal
- Kasr El-Ainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Ajay Sharma
- Royal Liverpool University Hospital, Royal Liverpool University Hospital, Liverpool L7 8YE, United Kingdom
| | - Ahmed Halawa
- Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
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11
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Wilson NK, Schulz P, Wall A, Parrott M, Testa G, Johannesson L, Sam T. Immunosuppression in Uterus Transplantation: Experience From the Dallas Uterus Transplant Study. Transplantation 2023; 107:729-736. [PMID: 36445981 DOI: 10.1097/tp.0000000000004437] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND Uterus transplantation is a temporary transplant allowing women with absolute uterine factor infertility to experience pregnancy and childbirth. The degree of immunosuppression (IS) required to prevent rejection while minimizing toxicity to the recipient and fetus remains an area of investigation. METHODS In this article, we describe immunosuppressive therapy, rejection episodes, infections, and adverse events in 14 uterus transplant recipients. Induction consisted of antithymocyte globulin and methylprednisolone. Ten recipients (71%) received no steroids postoperatively, and 4 (29%) had steroids tapered off at 42 d. All received oral tacrolimus, either immediate release (n = 2, 14%) or extended release (n = 12, 86%). Mycophenolate was used in 4 cases (29%), de novo azathioprine in 9 (64%), and de novo everolimus in 1 (7%). RESULTS Sixteen clinically silent, treatment-responsive rejection episodes occurred in 10 recipients. Five recipients (36%) experienced acute kidney injury. In 3 recipients, IS was discontinued due to renal dysfunction. Eleven infection episodes were noted in 7 recipients. No babies had congenital abnormalities. CONCLUSIONS Our experience demonstrates that safe IS regimens can be used for uterus transplant recipients before and during pregnancy.
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Affiliation(s)
- Nicole K Wilson
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX
| | - Philipp Schulz
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Anji Wall
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Megan Parrott
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Liza Johannesson
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - Teena Sam
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX
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12
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Al-Husayni N, Maslyanskaya S, Rubinstein TB, Coupey SM. Reproductive Health Care for Female Adolescents Prescribed Mycophenolate at a Children's Hospital: A 10-Year Retrospective Cohort Study. J Pediatr 2023; 253:252-258. [PMID: 36208664 DOI: 10.1016/j.jpeds.2022.09.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To describe female adolescents' reproductive health needs and subspecialists' teratogenic counseling at initiation of mycophenolate as well as use of reproductive health care and contraception after mycophenolate initiation. STUDY DESIGN We searched health records for female patients aged 12-20 years prescribed mycophenolate from 2010 to 2019. We included 125 subjects, 72 with systemic lupus erythematosus, 27 with transplants, and 26 with other conditions. We reviewed all encounters with pediatric subspecialists and reproductive clinicians. We recorded counseling by subspecialists at mycophenolate initiation and compared rates pre- and post-Risk Evaluation and Mitigation Strategy (REMS). We recorded subjects' menstrual, sexual and pregnancy history, type of first highly effective contraceptive method used, and duration of use over the decade. RESULTS At mycophenolate initiation, mean age was 16.8 ± 2.6 years; 72% Hispanic/Latina or Black. In total, 80% were postmenarchal, 28% ever had sex, 18% ever had a reproductive health care visit, 14% used highly effective contraception, and 7% were ever pregnant. Post-REMS vs pre-REMS, we found greater rates of counseling for teratogenicity (68% vs 32%, P < .001) and contraception (62% vs 32%, P < .001) and pregnancy testing (51% vs 24%, P < .01). Over the mean 4.9 ± 3.3 years' follow-up, 56% ever had sex; 59% ever attended a reproductive health care visit; 38% used highly effective contraception; and 10% had a pregnancy. CONCLUSIONS Adolescents prescribed mycophenolate have ongoing unmet reproductive health care needs. Although many are sexually active, fewer use effective contraception. Teratogenicity counseling rates improved over the decade but not rates of referral for reproductive health care.
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Affiliation(s)
- Noor Al-Husayni
- Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, NY
| | - Sofya Maslyanskaya
- Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, NY; Pediatrics, Albert Einstein College of Medicine, Bronx, NY.
| | - Tamar B Rubinstein
- Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Division of Pediatric Rheumatology, Children's Hospital at Montefiore, Bronx, NY
| | - Susan M Coupey
- Division of Adolescent Medicine, Children's Hospital at Montefiore, Bronx, NY; Pediatrics, Albert Einstein College of Medicine, Bronx, NY
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13
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Pulmonary disorders in pregnancy: Bronchiectasis, cystic fibrosis, sarcoidosis and interstitial diseases. Best Pract Res Clin Obstet Gynaecol 2022; 85:114-126. [PMID: 36244873 DOI: 10.1016/j.bpobgyn.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 12/14/2022]
Abstract
This chapter aims to provide expert guidance to obstetricians, general practitioners, allied health staff and women with lung disease about the interactions between pregnancy and different lung diseases. This chapter will cover other airway diseases such as bronchiectasis and cystic fibrosis (CF) together with sarcoidosis and interstitial lung disease (ILD), noting that another chapter covers asthma. The physiological changes which occur in pregnancy, such as the changes in airway physiology, resting ventilation and sleep, are summarised in another chapter. This chapter extends the evidence-based approach and clinical expertise of the recent European Respiratory Society/Thoracic Society of Australia and New Zealand (ERS/TSANZ) taskforce. The papers selected were based on the population (pregnant women with lung disease other than asthma) and the effects of these diseases on risks of pregnancy-associated complications and miscarriages, breastfeeding, nutritional considerations, lung function, long-term maternal outcomes and management considerations during pregnancy. As there are very few randomised control trials in the area, the majority of the literature consists of observational studies (prospective or retrospective), cross-sectional surveys and case series. Other guidelines have also recently been published, which may be helpful to the reader.
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14
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Castle JT, Levy BE, Rodeberg DA. Abdominal Tumors. Surg Clin North Am 2022; 102:715-737. [DOI: 10.1016/j.suc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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15
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Grant-Orser A, Metcalfe A, Pope JE, Johannson KA. Pregnancy Considerations for Patients With Interstitial Lung Disease. Chest 2022; 162:1093-1105. [PMID: 35779609 DOI: 10.1016/j.chest.2022.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 06/16/2022] [Accepted: 06/22/2022] [Indexed: 12/29/2022] Open
Abstract
Advances in our understanding of interstitial lung disease (ILD) pathophysiology and natural history have led to the development of guidelines for the diagnosis and management of several of these complex diseases. The demographics of patients with ILD indicate the disease is not restricted to older adults. Connective tissue disease-associated ILD, familial pulmonary fibrosis, and post-COVID-19 fibrosis may affect women of child-bearing age. Recent trials have excluded pregnant women, thereby limiting the applicability of contemporary therapeutic advances to these patients. This review synthesizes the current knowledge of pregnancy outcomes in those with ILD, with a focus on connective tissue disease-associated ILD, and potential treatment implications for patients with ILD who are pregnant or considering pregnancy. Pregnancy considerations for patients with ILD include the need for preconception counseling and planning to ensure disease stability, medication and vaccination optimization, and multidisciplinary involvement of a patient's pulmonologist, obstetrician, and, when indicated, rheumatologist and genetic counselor. Evidence to date suggests that women with ILD can have safe and healthy pregnancies but that complications may occur in those with severe ILD.
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Affiliation(s)
- Amanda Grant-Orser
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Amy Metcalfe
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Janet E Pope
- Division of Rheumatology, Department of Medicine, University of Western Ontario, St. Joseph's Health Care, London, ON, Canada
| | - Kerri A Johannson
- Division of Respirology, Department of Medicine, University of Calgary, Calgary, AB, Canada; Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada; Snyder Institute for Chronic Diseases, University of Calgary, Calgary, AB, Canada
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16
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Khan F, Syed F, AbdulMuthalib H, Dammas N, Al Alaiyan S, Al Hazzani F, Kattan A, Bin Jabr M, Bin Manea A, Almidani E. Fetal malformations associated with exposure to mycophenolic acid during the first trimester. Int J Pediatr Adolesc Med 2022; 9:171-173. [PMID: 36090133 PMCID: PMC9441254 DOI: 10.1016/j.ijpam.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/02/2022] [Accepted: 02/20/2022] [Indexed: 12/03/2022]
Abstract
Mycophenolic acid [MPA] is a powerful inhibitor of lymphocyte proliferation. Although this drug has been used across the globe for various maternal comorbidities, multiple concerns have been raised regarding its teratogenic effects. The Food and Drug Administration has changed its category to drug category D (evidence of fetal risk) in 2007. A wide range of congenital malformations in infants born to a mother using this medication have been described in the literature, but there is no specific set pattern of these malformations. We report a case of a female infant who had exposure to mycophenolate by maternal use during the initial phase of 1st trimester of her pregnancy and ended up having multiple congenital malformations. She was managed with multidisciplinary approach and was finally discharged home on respiratory support, after two months of hospital stay. The fact that our patient shared a pattern of congenital malformations with other reported cases who were exposed to mycophenolate in utero strongly suggests that mycophenolate had a causal role and that there might be an emerging fetal mycophenolate mofetil syndrome (FMMS).
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17
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Tingaud-Sequeira A, Trimouille A, Sagardoy T, Lacombe D, Rooryck-Thambo C. Oculo-auriculo-vertebral spectrum: new genes and literature review on a complex disease. J Med Genet 2022; 59:417-427. [PMID: 35110414 DOI: 10.1136/jmedgenet-2021-108219] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/30/2021] [Indexed: 12/23/2022]
Abstract
Oculo-auriculo-vertebral spectrum (OAVS) or Goldenhar syndrome is due to an abnormal development of first and second branchial arches derivatives during embryogenesis and is characterised by hemifacial microsomia associated with auricular, ocular and vertebral malformations. The clinical and genetic heterogeneity of this spectrum with incomplete penetrance and variable expressivity, render its molecular diagnosis difficult. Only a few recurrent CNVs and genes have been identified as causatives in this complex disorder so far. Prenatal environmental causal factors have also been hypothesised. However, most of the patients remain without aetiology. In this review, we aim at updating clinical diagnostic criteria and describing genetic and non-genetic aetiologies, animal models as well as novel diagnostic tools and surgical management, in order to help and improve clinical care and genetic counselling of these patients and their families.
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Affiliation(s)
- Angèle Tingaud-Sequeira
- Univ. Bordeaux, Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, F-33000 Bordeaux, France
| | - Aurélien Trimouille
- Univ. Bordeaux, Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, F-33000 Bordeaux, France.,CHU de Bordeaux, Service de Génétique Médicale, Centre de Référence Anomalies du Développement et Syndromes Malformatifs, F-33076, Bordeaux, France
| | - Thomas Sagardoy
- CHU de Bordeaux, Service d'oto-rhino-laryngologie, de chirurgie cervico-faciale et d'ORL pédiatrique, 33076 Bordeaux, France
| | - Didier Lacombe
- Univ. Bordeaux, Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, F-33000 Bordeaux, France.,CHU de Bordeaux, Service de Génétique Médicale, Centre de Référence Anomalies du Développement et Syndromes Malformatifs, F-33076, Bordeaux, France
| | - Caroline Rooryck-Thambo
- Univ. Bordeaux, Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, F-33000 Bordeaux, France .,CHU de Bordeaux, Service de Génétique Médicale, Centre de Référence Anomalies du Développement et Syndromes Malformatifs, F-33076, Bordeaux, France
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18
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Selzer EB, Blain D, Hufnagel RB, Lupo PJ, Mitchell LE, Brooks BP. Review of Evidence for Environmental Causes of Uveal Coloboma. Surv Ophthalmol 2021; 67:1031-1047. [PMID: 34979194 DOI: 10.1016/j.survophthal.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
Uveal coloboma is a condition defined by missing ocular tissues and is a significant cause of childhood blindness. It occurs from a failure of the optic fissure to close during embryonic development,and may lead to missing parts of the iris, ciliary body, retina, choroid, and optic nerve. Because there is no treatment for coloboma, efforts have focused on prevention. While several genetic causes of coloboma have been identified, little definitive research exists regarding the environmental causes of this condition. We review the current literature on environmental factors associated with coloboma in an effort to guide future research and preventative counseling related to this condition.
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Affiliation(s)
- Evan B Selzer
- Ophthalmic Genetics & Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, MD
| | - Delphine Blain
- Ophthalmic Genetics & Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, MD
| | - Robert B Hufnagel
- Ophthalmic Genetics & Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, MD
| | - Philip J Lupo
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX
| | - Laura E Mitchell
- Department of Epidemiology, Human Genetics and Environmental Sciences, UTHealth School of Public Health, Houston, TX
| | - Brian P Brooks
- Ophthalmic Genetics & Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, MD.
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19
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Lin Y, Breugem CC, Maas SM, de Bakker BS, Li G. The important role of RPS14, RPL5 and MDM2 in TP53-associated ribosome stress in mycophenolic acid-induced microtia. Int J Pediatr Otorhinolaryngol 2021; 151:110916. [PMID: 34537545 DOI: 10.1016/j.ijporl.2021.110916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 08/26/2021] [Accepted: 09/03/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Mycophenolate embryopathy (ME) is a congenital malformation induced by mycophenolic acid (MA). Microtia is the most common ME phenotype. This study aimed to identify the key genes in the pathological process of microtia caused by mycophenolate mofetil (MM) through bioinformatics methods, to explore the potential pathogenesis, and to provide a direction for future genetic research on aetiology. METHODS Genes related to MM and microtia were obtained from the GeneCards database for bioinformatics. Metacore was used to identify and visualize the upstream and downstream gene relationships in the protein-protein interaction (PPI) results of these genes. The clusterProfiler R software package was used to simulate and visualize the enrichment results based on data from Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. RESULTS Fifty-nine genes were associated with microtia and MM/MA. The hub genes with the most significant effects on MM/MA-induced microtia pathogenesis included tumour protein P53 (p53), MDM2 proto-oncogene (MDM2), ribosomal protein L5 (RPL5) and ribosomal protein S14 (RBS14). The GO term with the most enriched genes was peptidyl-tyrosine phosphorylation. For the KEGG terms, there was significant enrichment regarding the haematopoietic cell lineage, apoptosis, p53 signalling, proteasome and necroptosis. CONCLUSIONS We propose that an axis composed of MA, microtia, TP53 and related genes is involved in ME pathogenesis. The important role of TP53-associated ribosome stress in ME pathogenesis is consistent with our previous findings from MA-induced cleft lip and palate. Deregulation of genes protective against TP53 overexpression, such as MDM2, could be a strategy for constructing a microtia animal model.
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Affiliation(s)
- Yangyang Lin
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam Medical Centre, Amsterdam, the Netherlands; Plastic Surgery Hospital, Peking Union Medical College, Beijing, China
| | - Corstiaan C Breugem
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam Medical Centre, Amsterdam, the Netherlands
| | - Saskia M Maas
- Amsterdam UMC, Department of Clinical Genetics, Academic Medical Center, Amsterdam, the Netherlands
| | - Bernadette S de Bakker
- Department of Medical Biology, Section Clinical Anatomy & Embryology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Gaofeng Li
- Department of Plastic and Cosmeitc Surgery, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, 61 Jiefangxi road, Changsha, 410005, Hunan, PR China.
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20
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Gouveia IF, Silva JR, Santos C, Carvalho C. Maternal and fetal outcomes of pregnancy in chronic kidney disease: diagnostic challenges, surveillance and treatment throughout the spectrum of kidney disease. ACTA ACUST UNITED AC 2021; 43:88-102. [PMID: 33460427 PMCID: PMC8061969 DOI: 10.1590/2175-8239-jbn-2020-0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/31/2020] [Indexed: 01/01/2023]
Abstract
Pregnancy requires several physiological adaptations from the maternal organism, including modifications in the glomerular filtration rate and renal excretion of several products. Chronic kidney disease (CKD) can negatively affect these modifications and consequently is associated with several adverse maternal and fetal adverse outcomes (gestational hypertension, progression of renal disease, pre-eclampsia, fetal growth restriction, and preterm delivery). A multidisciplinary vigilance of these pregnancies is essential in order to avoid and/or control the harmful effects associated with this pathology. Dialysis and transplantation can decrease the risks of maternal and fetal complications, nonetheless, the rates of complications remain high comparing with a normal pregnancy. Several recent developments in this area have improved quality and efficacy of treatment of pregnant women with CKD. This article summarizes the most recent literature about CKD and pregnancy.
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Affiliation(s)
- Inês Filipe Gouveia
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Joana Raquel Silva
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Clara Santos
- Serviço de Nefrologia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
| | - Claudina Carvalho
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar de Vila Nova de Gaia e Espinho, Portugal
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21
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Usage of Tacrolimus and Mycophenolic Acid During Conception, Pregnancy, and Lactation, and Its Implications for Therapeutic Drug Monitoring: A Systematic Critical Review. Ther Drug Monit 2021; 42:518-531. [PMID: 32398419 DOI: 10.1097/ftd.0000000000000769] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Conception, pregnancy, and lactation following solid organ transplantation require appropriate management. The most frequently used immunosuppressive drug combination after solid organ transplantation consists of tacrolimus (Tac) plus mycophenolic acid (MPA). Here, the effects of Tac and MPA on fertility, pregnancy, and lactation are systematically reviewed, and their implications for therapeutic drug monitoring (TDM) are discussed. METHODS A systematic literature search was performed (August 19, 2019) using Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science, and 102 studies were included. Another 60 were included from the reference list of the published articles. RESULTS As MPA is teratogenic, women who are trying to conceive are strongly recommended to switch from MPA to azathioprine. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes. Nevertheless, in 2015, the drug label was updated with additional risk minimization measures in a pregnancy prevention program. Data on MPA pharmacokinetics during pregnancy and lactation are limited. Tac treatment during conception, pregnancy, and lactation seems to be safe in terms of the health of the mother, (unborn) child, and allograft. However, Tac may increase the risk of hypertension, preeclampsia, preterm birth, and low birth weight. Infants will ingest very small amounts of Tac via breast milk from mothers treated with Tac. However, no adverse outcomes have been reported in children exposed to Tac during lactation. During pregnancy, changes in Tac pharmacokinetics result in increased unbound to whole-blood Tac concentration ratio. To maintain Tac concentrations within the target range, increased Tac dose and intensified TDM may be required. However, it is unclear if dose adjustments during pregnancy are necessary, considering the higher concentration of (active) unbound Tac. CONCLUSIONS Tac treatment during conception, pregnancy and lactation seems to be relatively safe. Due to pharmacokinetic changes during pregnancy, a higher Tac dose might be indicated to maintain target concentrations. However, more evidence is needed to make recommendations on both Tac dose adjustments and alternative matrices than whole-blood for TDM of Tac during pregnancy. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes, whereas MPA use in women during conception and pregnancy is strongly discouraged.
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22
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Abdulaziz HM, Shemies RS, Taman M, Mosbah A, Elkannishy G. Fetal proximal and distal limb anomalies following exposure to mycophenolate mofetil during pregnancy: A case report and review of the literature. Lupus 2021; 30:1522-1525. [PMID: 34082587 DOI: 10.1177/09612033211021486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Mycophenolate mofetil (MMF) is currently used in a wide spectrum of autoimmune diseases and has been rendered very effective in the management of systemic lupus erythematosus and lupus nephritis. MMF is known to be teratogenic (FDA category D) and therefore, women in childbearing period receiving MMF should be counselled to use effective contraceptive methods to avoid an unplanned pregnancy. CASE A 22-year-old lady accidentally discovered to be pregnant while using MMF as a treatment of lupus nephritis which was replaced later on by azathioprine. After maternal and fetal evaluation, maternal lupus flare was confirmed and multiple fetal skeletal deformities associated with intrauterine growth restriction (IUGR) were diagnosed by 4-dimensional ultrasound. Termination of pregnancy was decided after shared decision making. CONCLUSION Women in childbearing period should be advised to postpone pregnancy for at least six weeks after stoppage of MMF therapy because of its potential teratogenic effects during pregnancy.
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Affiliation(s)
- Hoda Mm Abdulaziz
- Mansoura Nephrology and Dialysis Unit (MNDU), Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Rasha Samir Shemies
- Mansoura Nephrology and Dialysis Unit (MNDU), Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Mohamed Taman
- Obstetrics and Gynecology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Alaa Mosbah
- Obstetrics and Gynecology Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Ghada Elkannishy
- Mansoura Nephrology and Dialysis Unit (MNDU), Faculty of Medicine, Mansoura University, Mansoura, Egypt
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23
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Lin Y, Song T, Ronde EM, Ma G, Cui H, Xu M. The important role of MDM2, RPL5, and TP53 in mycophenolic acid-induced cleft lip and palate. Medicine (Baltimore) 2021; 100:e26101. [PMID: 34032749 PMCID: PMC8154508 DOI: 10.1097/md.0000000000026101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 05/05/2021] [Indexed: 12/11/2022] Open
Abstract
Mycophenolate embryopathy (MPE) is a mycophenolic acid (MPA)-induced congenital malformation with distinctive symptoms. Cleft lip/palate (CLP) is one of the most common symptoms of MPE. The aim of this study was to screen and verify hub genes involved in MPA-induced CLP and to explore the potential molecular mechanisms underlying MPE.Overlapping genes related to MPA and CLP were obtained from the GeneCards database. These genes were further analyzed via bioinformatics. The Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis results were visualized with the Cytoscape ClueGO plug-in. Gene protein-protein interaction (PPI) networks were constructed based on data obtained from the Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) database.Overall, 58 genes related to MPA and CLP were identified. The genes most relevant to MPA-induced CLP included ABCB1, COL1A1, Rac1, TGFβ1, EDN1, and TP53, as well as the TP53-associated genes MDM2 and RPL5. GO analysis demonstrated gene enrichment regarding such terms as ear, mesenchymal, striated muscle, and ureteric development. KEGG analysis demonstrated gene enrichment in such pathways as the HIF-1 signaling pathway, glycosylphosphatidylinositol-anchor biosynthesis, the TNF signaling pathway, and hematopoietic stem cell development.Bioinformatic analysis was performed on the genes currently known to be associated with MPA-induced CLP pathogenesis. MPA-induced CLP is mediated by multiple ribosome stress related genes and pathways. MDM2, RPL5 and TP53 could be the main contributor in this pathogenesis, along with several other genes. ABCB1 polymorphism could be related to the probability of MPA-induced CLP.
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Affiliation(s)
- Yangyang Lin
- Plastic Surgery Hospital of Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam Medical Centre, Amsterdam, The Netherlands
- People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Tao Song
- Plastic Surgery Hospital of Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing
| | - Elsa M. Ronde
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - Gang Ma
- People's Hospital of Guangxi Zhuang Autonomous Region, Nanning
| | - Huiqin Cui
- The Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, China
| | - Meng Xu
- Plastic Surgery Hospital of Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing
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24
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Jones BP, Saso S, Yazbek J, Thum MY, Quiroga I, Ghaem-Maghami S, Smith JR. Uterine Transplantation: Scientific Impact Paper No. 65 April 2021. BJOG 2021; 128:e51-e66. [PMID: 33913235 DOI: 10.1111/1471-0528.16697] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
A uterine transplant, or womb transplant, provides a potential treatment for women who cannot become pregnant or carry a pregnancy because they do not have a womb, or have a womb that is unable to maintain a pregnancy. This is estimated to affect one in 500 women. Options for those who wish to start a family include adoption and surrogacy, but these are associated with legal, cultural, ethical and religious implications that may not be appropriate for some women and their families. A womb transplant is undertaken when the woman is ready to start a family, and is removed following the completion of their family. Womb transplants have been performed all over the world, with more than 70 procedures carried out so far. At least 23 babies have been born as a result, demonstrating that womb transplants can work. While the procedure offers a different option to adoption and surrogacy, it is associated with significant risks, including multiple major surgeries and the need to take medications that help to dampen the immune system to prevent rejection of the womb. To date there has been a 30% risk of a transplant being unsuccessful. Although the number of transplants to date is still relatively small, the number being performed globally is growing, providing an opportunity to learn from the experience gained so far. This paper looks at the issues that have been encountered, which may arise at each step of the process, and proposes a framework for the future. However, long term follow-up of cases will be essential to draw reliable conclusions about any overall benefits of this procedure.
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Affiliation(s)
- B P Jones
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - S Saso
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - J Yazbek
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - M-Y Thum
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - I Quiroga
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - S Ghaem-Maghami
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - J R Smith
- Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
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25
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Diaz-Gonzalez de Ferris ME, Díaz-González de Martínez MDL, Díaz-González de Velázquez AM, Díaz-González Borja A, Díaz-González Borja A, Filler G, Alvarez-Elías AC, Díaz-González Borja V. An Interdisciplinary Approach to Optimize the Care of Transitioning Adolescents and Young Adults with CKD. Blood Purif 2021; 50:684-695. [PMID: 33706317 DOI: 10.1159/000513520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/27/2020] [Indexed: 11/19/2022]
Abstract
Adolescents and young adults (AYAs) with CKD or end-stage kidney disease (ESKD) have unique medical, dental, psychosocial, neurocognitive, and academic needs and require close interdisciplinary collaboration to optimize their care. The etiology of CKD in AYAs is diverse compared to older adults. With their continuously improved survival, AYAs must start preparation for health-care transition (HCT) from pediatric- to adult-focused health care in the pediatric setting and it must continue at the adult-focused setting, given that their brain maturation and self-management skill acquisition occur until their mid-20s. While the growth and physical maturation of most visible body parts occur before 18 years of age, the prefrontal cortex of the brain, where reasoning, impulse control, and other higher executive functions reside, matures around 25 years of age. The HCT process must be monitored using patient- and caregiver-measuring tools to guide interventions. The HCT process becomes more complex when patients and/or caregivers have a language barrier, different cultural beliefs, or lower literacy levels. In this article, we discuss the unique comorbidities of pediatric-onset CKD/ESKD, provide information for a planned HCT preparation, and suggest interdisciplinary coordination as well as cultural and literacy-appropriate activities to achieve optimal patient outcomes.
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Affiliation(s)
| | - María de Lourdes Díaz-González de Martínez
- Escuela de Biotecnología, Universidad Mexicana del Estado de Mexico (UNIMEX), Mexico City, Mexico.,Ciencias de la Salud y Metodología de la Investigación, Escuela Preparatoria Oficial Anexa a la Normal de Cuautitlán-Izacalli, Estado de México, Mexico
| | | | | | | | - Guido Filler
- Departments of Paediatrics, University of Western Ontario, London, Ontario, Canada.,Departments of Medicine, University of Western Ontario, London, Ontario, Canada.,Departments of Pathology & Laboratory Medicine, University of Western Ontario, London, Ontario, Canada.,Lilibeth Caberto Kidney Clinical Research Unit, London, Ontario, Canada
| | - Ana Catalina Alvarez-Elías
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Unidad de Investigación y Diagnóstico en Nefrología y Metabolismo Mineral Óseo, Hospital Infantil de México, Federico Gómez, Mexico City, Mexico.,Unidad de Estudios de Posgrado, Universidad Nacional Autónoma de, Mexico City, Mexico
| | - Vicente Díaz-González Borja
- San Ysidro Health, San Diego, California, USA.,Department of Medicine, Universidad Autónoma de Guadalajara, Guadalajara, Mexico
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26
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Martin-Moreno PL, Sánchez-Fructuoso AI, Mazuecos A, Mir M, Lopez-Lopez I, González-Rinne A, Coca A, Valero R, Ventura Galiano A, Ridao N, Toapanta-Gaibor NG, Fernández-Tagarro E, Cruzado-Vega L, Pérez-Mir M, Jiménez C. Paternal safety of the use of mycophenolic acid in kidney transplant recipients. Results of the EMVARON study. Clin Transplant 2021; 35:e14256. [PMID: 33599030 DOI: 10.1111/ctr.14256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 02/06/2021] [Accepted: 02/12/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND The use of mycophenolic acid (MPA) in women during pregnancy causes an increase in miscarriages and birth defects with a typical embryopathy profile. Although epidemiological data does not suggest a greater risk among the offspring of male kidney transplant recipients, the European Medicines Agency and The Spanish Agency of Medicines and Medical Devices introduced the recommendation of using contraceptive methods. METHODS We conducted a national retrospective study in 15 Spanish Kidney Transplant Centers to evaluate the frequency of miscarriages and birth defects between the offspring from male kidney transplants recipients. We included 151 males who had fathered 239 offspring, 225 under MPA and 14 without MPA. RESULTS The results of our study showed an incidence of miscarriages in the MPA group of 9.8%, and of birth defects of 4%. CONCLUSIONS We observed an incidence of miscarriages between the offspring fathered by kidney transplant males under MPA lower than the general population. The incidence of birth defects was similar to the incidence described in other studies and the fact that we did not find the typical embryopathy profile makes it difficult to associate them to the use of MPA. Because of that, we urge the European and Spanish Agencies to reconsider their recommendations for males.
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Affiliation(s)
- Paloma L Martin-Moreno
- Nephrology Department, Clínica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | | | | | - Marisa Mir
- Nephrology Department, Hospital del Mar, Barcelona, Spain
| | - Isabel Lopez-Lopez
- Nephrology Department, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Ana González-Rinne
- Nephrology Department, Hospital Universitario de Canarias, Instituto de Tecnologías Biomédicas (ITB)-Universidad de La Laguna, Tenerife, Spain
| | - Armando Coca
- Nephrology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Rosalía Valero
- Nephrology Department, H.U. Marqués de Valdecilla, IDIVAL, Universidad de Cantabria, Santander, Spain
| | - Ana Ventura Galiano
- Kidney Transplant Unit, Hospital Universitari i Politécnic La Fe, Valencia, Spain
| | - Natalia Ridao
- Nephrology Department, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Ernesto Fernández-Tagarro
- Nephrology Department, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas, Spain
| | | | - Mónica Pérez-Mir
- Kidney Transplant Unit, Nephrology Department, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carlos Jiménez
- Nephrology Department, Hospital Universitario La Paz, Madrid, Spain
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27
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Tingaud-Sequeira A, Trimouille A, Salaria M, Stapleton R, Claverol S, Plaisant C, Bonneu M, Lopez E, Arveiler B, Lacombe D, Rooryck C. A recurrent missense variant in EYA3 gene is associated with oculo-auriculo-vertebral spectrum. Hum Genet 2021; 140:933-944. [PMID: 33475861 DOI: 10.1007/s00439-021-02255-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/06/2021] [Indexed: 12/18/2022]
Abstract
Goldenhar syndrome or oculo-auriculo-vertebral spectrum (OAVS) is a complex developmental disorder characterized by asymmetric ear anomalies, hemifacial microsomia, ocular and vertebral defects. We aimed at identifying and characterizing a new gene associated with OAVS. Two affected brothers with OAVS were analyzed by exome sequencing that revealed a missense variant (p.(Asn358Ser)) in the EYA3 gene. EYA3 screening was then performed in 122 OAVS patients that identified the same variant in one individual from an unrelated family. Segregation assessment in both families showed incomplete penetrance and variable expressivity. We investigated this variant in cellular models to determine its pathogenicity and demonstrated an increased half-life of the mutated protein without impact on its ability to dephosphorylate H2AFX following DNA repair pathway induction. Proteomics performed on this cellular model revealed four significantly predicted upstream regulators which are PPARGC1B, YAP1, NFE2L2 and MYC. Moreover, eya3 knocked-down zebrafish embryos developed specific craniofacial abnormalities corroborating previous animal models and supporting its involvement in the OAVS. Additionally, EYA3 gene expression was deregulated in vitro by retinoic acid exposure. EYA3 is the second recurrent gene identified to be associated with OAVS. Moreover, based on protein interactions and related diseases, we suggest the DNA repair as a key molecular pathway involved in craniofacial development.
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Affiliation(s)
- Angèle Tingaud-Sequeira
- Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, Univ. Bordeaux, 33000, Bordeaux, France
| | - Aurélien Trimouille
- Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, Univ. Bordeaux, 33000, Bordeaux, France.,CHU de Bordeaux, Service de Génétique Médicale, Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU Pellegrin-Ecole des Sages-femmes, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France
| | - Manju Salaria
- Genetic Health Service, Monash Health, 246 Clayton Road, Clayton, VIC, 3168, Australia.,Wyndham Specialist Care Centre, 289 Princes Highway, Werribee, VIC, 3030, Australia
| | - Rachel Stapleton
- Genetic Health Service NZ-South Island Hub, Christchurch Hospital, Christchurch, 8140, New Zealand
| | - Stéphane Claverol
- Plateforme Protéome, Centre Génomique Fonctionnelle Bordeaux, Bordeaux, France
| | - Claudio Plaisant
- CHU de Bordeaux, Service de Génétique Médicale, Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU Pellegrin-Ecole des Sages-femmes, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France
| | - Marc Bonneu
- Plateforme Protéome, Centre Génomique Fonctionnelle Bordeaux, Bordeaux, France
| | - Estelle Lopez
- Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, Univ. Bordeaux, 33000, Bordeaux, France
| | - Benoit Arveiler
- Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, Univ. Bordeaux, 33000, Bordeaux, France.,CHU de Bordeaux, Service de Génétique Médicale, Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU Pellegrin-Ecole des Sages-femmes, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France
| | - Didier Lacombe
- Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, Univ. Bordeaux, 33000, Bordeaux, France.,CHU de Bordeaux, Service de Génétique Médicale, Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU Pellegrin-Ecole des Sages-femmes, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France
| | - Caroline Rooryck
- Maladies Rares: Génétique et Métabolisme (MRGM), U 1211 INSERM, Univ. Bordeaux, 33000, Bordeaux, France. .,CHU de Bordeaux, Service de Génétique Médicale, Centre de Référence Anomalies du Développement et Syndromes Malformatifs, CHU Pellegrin-Ecole des Sages-femmes, Place Amélie Raba-Léon, 33076, Bordeaux Cedex, France.
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28
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Brosens E, Peters NCJ, van Weelden KS, Bendixen C, Brouwer RWW, Sleutels F, Bruggenwirth HT, van Ijcken WFJ, Veenma DCM, Otter SCMCD, Wijnen RMH, Eggink AJ, van Dooren MF, Reutter HM, Rottier RJ, Schnater JM, Tibboel D, de Klein A. Unraveling the Genetics of Congenital Diaphragmatic Hernia: An Ongoing Challenge. Front Pediatr 2021; 9:800915. [PMID: 35186825 PMCID: PMC8852845 DOI: 10.3389/fped.2021.800915] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/28/2021] [Indexed: 12/16/2022] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a congenital structural anomaly in which the diaphragm has not developed properly. It may occur either as an isolated anomaly or with additional anomalies. It is thought to be a multifactorial disease in which genetic factors could either substantially contribute to or directly result in the developmental defect. Patients with aneuploidies, pathogenic variants or de novo Copy Number Variations (CNVs) impacting specific genes and loci develop CDH typically in the form of a monogenetic syndrome. These patients often have other associated anatomical malformations. In patients without a known monogenetic syndrome, an increased genetic burden of de novo coding variants contributes to disease development. In early years, genetic evaluation was based on karyotyping and SNP-array. Today, genomes are commonly analyzed with next generation sequencing (NGS) based approaches. While more potential pathogenic variants are being detected, analysis of the data presents a bottleneck-largely due to the lack of full appreciation of the functional consequence and/or relevance of the detected variant. The exact heritability of CDH is still unknown. Damaging de novo alterations are associated with the more severe and complex phenotypes and worse clinical outcome. Phenotypic, genetic-and likely mechanistic-variability hampers individual patient diagnosis, short and long-term morbidity prediction and subsequent care strategies. Detailed phenotyping, clinical follow-up at regular intervals and detailed registries are needed to find associations between long-term morbidity, genetic alterations, and clinical parameters. Since CDH is a relatively rare disorder with only a few recurrent changes large cohorts of patients are needed to identify genetic associations. Retrospective whole genome sequencing of historical patient cohorts using will yield valuable data from which today's patients and parents will profit Trio whole genome sequencing has an excellent potential for future re-analysis and data-sharing increasing the chance to provide a genetic diagnosis and predict clinical prognosis. In this review, we explore the pitfalls and challenges in the analysis and interpretation of genetic information, present what is currently known and what still needs further study, and propose strategies to reap the benefits of genetic screening.
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Affiliation(s)
- Erwin Brosens
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Nina C J Peters
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Kim S van Weelden
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Charlotte Bendixen
- Unit of Pediatric Surgery, Department of General, Visceral, Vascular and Thoracic Surgery, University Hospital Bonn, Bonn, Germany
| | - Rutger W W Brouwer
- Center for Biomics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Cell Biology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Frank Sleutels
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Hennie T Bruggenwirth
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Wilfred F J van Ijcken
- Center for Biomics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Cell Biology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Danielle C M Veenma
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Pediatrics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Suzan C M Cochius-Den Otter
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Rene M H Wijnen
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Alex J Eggink
- Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynecology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Marieke F van Dooren
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Heiko Martin Reutter
- Institute of Human Genetics, University Hospital of Bonn, Bonn, Germany.,Neonatology and Pediatric Intensive Care, Department of Pediatrics and Adolescent Medicine, University Hospital Erlangen, Erlangen, Germany
| | - Robbert J Rottier
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands.,Department of Cell Biology, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - J Marco Schnater
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Annelies de Klein
- Department of Clinical Genetics, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
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29
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Uterine Transplantation: Evolving Data, Success, and Clinical Importance. J Minim Invasive Gynecol 2020; 28:502-512. [PMID: 33348011 DOI: 10.1016/j.jmig.2020.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/09/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022]
Abstract
Uterine transplantation is an evolving procedure to allow for childbearing in paitents with absolute uterine factor infertility. The objective of this study was to review the existing literature using a comprehensive PubMed literature search. A systematic medical subheadings search strategy was used with the terms "uterus transplant" and "uterine transplantation". Of the 75 full-text articles assessed for eligibility, 68 were included in the qualitative synthesis. Of these, 9 were included in the meta-analysis on living donor uterine transplant, 5 on deceased donor uterine transplant, and 6 case reports of single uterine transplants. In conclusion, uterus transplant is a nascent field undergoing a rapid rate of evolution as programs mature their data and increase the number of procedures performed. The most recent publications and advances are thus summarized in this article to capture the most up-to-date information.
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30
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Yu B, Liu Z, Zhang C, Wu Y, Han J, Li H, Xu B, Guo H, Zhang K. Allogeneic uterus transplantation in a rhesus model: A short-term graft viability study. PLoS One 2020; 15:e0243140. [PMID: 33332374 PMCID: PMC7746281 DOI: 10.1371/journal.pone.0243140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/17/2020] [Indexed: 11/19/2022] Open
Abstract
Objective This study examined the feasibility and safety of allogeneic uterus transplantation (UTx) from a living donor and assessed short-term graft viability in a rhesus model. This research is an important step towards further clinical application of UTx in humans. Materials and methods Four female rhesus monkeys with regular menstrual cycles were used in this study, the animals were either donors or recipients depending on ABO blood type compatibility. Retrieval surgery was performed to connect the uterus and uterine arteries together with the ovarian uterine vein from the living donor, and the vagina of the recipient was excised. After the back table had been prepared, bilateral uterine arteries were anastomosed end-to-side with the iliac externa arteries, and bilateral ovarian uterine veins were anastomosed end-to-side with the iliac externa vena. The transplanted uterus was evaluated based on the conditions of arterial blood, and flow was evaluated by transabdominal ultrasonography one month post operation. The conditions of the transplanted uterus were examined by secondary laparotomy. The reproductive function of rhesus monkeys was evaluated on the basis of the menstrual cycle. Results All 4 rhesus monkeys received the transplantation surgery without any surgical complications. No injury occurred in the other organs, and no vascular injury was observed in the allogeneic uterus. All recipients survived after the surgery with a 100% short-term survival rate. All recipients resumed normal menstruation within two months after surgery. Conclusions Our short follow-up shows that allogeneic UTx surgery is a safe and feasible technology in the rhesus model. The arterial conditions and blood flow of the grafted uterus can be monitored by ultrasonography examination.
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Affiliation(s)
- Bo Yu
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
| | - Zhongyu Liu
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
| | - Chunyu Zhang
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
| | - Yu Wu
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
| | - Jinsong Han
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
| | - Huajun Li
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
| | - Bing Xu
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
| | - Hongyan Guo
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
- * E-mail: (HG); (KZ)
| | - Kun Zhang
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Beijing, PR China
- * E-mail: (HG); (KZ)
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31
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Bruijstens AL, Wendel EM, Lechner C, Bartels F, Finke C, Breu M, Flet-Berliac L, de Chalus A, Adamsbaum C, Capobianco M, Laetitia G, Hacohen Y, Hemingway C, Wassmer E, Lim M, Baumann M, Wickström R, Armangue T, Rostasy K, Deiva K, Neuteboom RF. E.U. paediatric MOG consortium consensus: Part 5 - Treatment of paediatric myelin oligodendrocyte glycoprotein antibody-associated disorders. Eur J Paediatr Neurol 2020; 29:41-53. [PMID: 33176999 DOI: 10.1016/j.ejpn.2020.10.005] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 02/06/2023]
Abstract
In recent years, the understanding about the different clinical phenotypes, diagnostic and prognostic factors of myelin oligodendrocyte glycoprotein-antibody-associated disorders (MOGAD) has significantly increased. However, there is still lack of evidence-based treatment protocols for acute attacks and children with a relapsing course of the disease. Currently used acute and maintenance treatment regimens are derived from other demyelinating central nervous system diseases and are mostly centre-specific. Therefore, this part of the Paediatric European Collaborative Consensus attempts to provide recommendations for acute and maintenance therapy based on clinical experience and evidence available from mainly retrospective studies. In the acute attack, intravenous methylprednisolone (IVMP) leads to a favourable outcome in the majority of patients and can be followed by tapering of oral steroids up to a maximum of three months to maintain the benefit of acute treatment by suppressing disease activity. Intravenous immunoglobulins (IVIG) and plasmapheresis constitute second-line therapies in case of insufficient response to IVMP. After a first relapse, maintenance treatment should be started in order to prevent further relapses and the possibility of permanent sequelae. Four first-line therapies consisting of rituximab (RTX), azathioprine, mycophenolate mofetil or monthly IVIG have been identified by the consensus group. In case of further relapses despite maintenance treatment, the consensus group recommends treatment escalation with RTX or IVIG, followed by combining those two, and ultimately adding maintenance oral steroids. Many open questions remain which need to be addressed in further international prospective evaluation of MOGAD treatment. This international collaboration is essential to expand the state of current knowledge.
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Affiliation(s)
| | - Eva-Maria Wendel
- Department of Paediatrics, Klinikum Stuttgart/Olgahospital, Stuttgart, Germany
| | - Christian Lechner
- Department of Paediatrics, Division of Paediatric Neurology, Medical University of Innsbruck, Austria
| | - Frederik Bartels
- Department of Neurology, Charité - Universitätsmedizin Berlin / Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Germany
| | - Carsten Finke
- Department of Neurology, Charité - Universitätsmedizin Berlin / Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Germany
| | - Markus Breu
- Department of Paediatrics and Adolescent Medicine, Division of Paediatric Neurology, Medical University of Vienna, Austria
| | - Lorraine Flet-Berliac
- Department of Paediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris-Saclay, Bicêtre Hospital and Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - Aliénor de Chalus
- Department of Paediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris-Saclay, Bicêtre Hospital and Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - Catherine Adamsbaum
- Paediatric Radiology Department, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris-Saclay, Bicêtre Hospital and Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - Marco Capobianco
- Department of Neurology and Regional Multiple Sclerosis Centre, University Hospital San Luigi Gonzaga, Orbassano, Italy
| | - Giorgi Laetitia
- Department of Paediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris-Saclay, Bicêtre Hospital and Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, France
| | - Yael Hacohen
- Department of Neuroinflammation, Queen Square Multiple Sclerosis Centre, UCL Institute of Neurology / Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Cheryl Hemingway
- Department of Paediatric Neurology, Great Ormond Street Hospital for Children, London, UK
| | - Evangeline Wassmer
- Department of Paediatric Neurology, Birmingham Children's Hospital, Birmingham, UK
| | - Ming Lim
- Children's Neurosciences, Evelina London Children's Hospital at Guy's and St Thomas' National Health Service Foundation Trust, London, Faculty of Life Sciences and Medicine, Kings College Hospital, London, UK
| | - Matthias Baumann
- Department of Paediatrics, Division of Paediatric Neurology, Medical University of Innsbruck, Austria
| | - Ronny Wickström
- Neuropaediatric Unit, Karolinska University Hospital, Sweden
| | - Thaís Armangue
- Neuroimmunology Program, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Paediatric Neuroimmunology Unit, Neurology Department, Sant Joan de Déu (SJD) Children's Hospital, University of Barcelona, Barcelona, Spain
| | - Kevin Rostasy
- Department of Paediatric Neurology, Children's Hospital Datteln, Witten/Herdecke University, Datteln, Germany
| | - Kumaran Deiva
- Department of Paediatric Neurology, Assistance Publique-Hôpitaux de Paris, University Hospitals Paris-Saclay, Bicêtre Hospital and Faculty of Medicine, Paris-Saclay University, Le Kremlin Bicêtre, France; French Reference Network of Rare Inflammatory Brain and Spinal Diseases, Le Kremlin Bicêtre, France and European Reference Network-RITA
| | - Rinze F Neuteboom
- Department of Neurology, Erasmus Medical Center, Rotterdam, the Netherlands
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Lacquaniti A, Campo S, Casuscelli Di Tocco T, Rovito S, Bucca M, Ragusa A, Monardo P. Acute and chronic kidney disease after pediatric liver transplantation: An underestimated problem. Clin Transplant 2020; 34:e14082. [PMID: 32949054 DOI: 10.1111/ctr.14082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 08/02/2020] [Accepted: 08/15/2020] [Indexed: 12/13/2022]
Abstract
Acute and chronic kidney injuries represent critical issues after liver transplantation (LTx), but whereas renal dysfunction in adult transplant patients is well documented, little is known about its prevalence in childhood. It is a challenge to accurately evaluate renal function in patients with liver disease, due to several confounding factors. Creatinine-based equations estimating glomerular filtration rate, validated in nephropathic patients without hepatic issues, are frequently inaccurate in end-stage liver disease, underestimating the real impact of renal disease. Moreover, whereas renal issues observed within 1 year from LTx were often related to acute injuries, kidney damage observed after 5-7 years from LTx, is due to chronic, irreversible mechanisms. Most immunosuppression protocols are based on calcineurin inhibitors (CNIs) and corticosteroids, but mycophenolate mofetil or sirolimus could play significant roles, also in children. Early diagnosis and personalized treatment represent the bases of kidney disease management, in order to minimize its close relation with increased mortality. This review analyzed acute and chronic kidney damage after pediatric LTx, also discussing the impact of pre-existent renal disease. The main immunosuppressant strategies have been reviewed, highlighting their impact on kidney function. Different methods assessing renal function were reported, with the potential application of new renal biomarkers.
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Affiliation(s)
- Antonio Lacquaniti
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Susanna Campo
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Teresa Casuscelli Di Tocco
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Stefania Rovito
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Maurizio Bucca
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Antonino Ragusa
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
| | - Paolo Monardo
- Department of Internal Medicine, Nephrology and Dialysis Unit, Papardo Hospital of Messina, Messina, Italy
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Zhang R, Deng SL, Lian ZX, Yu K. Immunosuppression in uterine transplantation. Transpl Immunol 2020; 63:101335. [PMID: 32927095 DOI: 10.1016/j.trim.2020.101335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/09/2020] [Indexed: 11/25/2022]
Abstract
Uterine transplantation (UTx) is the only effective treatment for uterine infertility patients to become genetic mothers. After decades of research, the surgical methods of UTx are very developed. There are numerous factors that affect the results of UTx, such as selection of the donor uterus before transplantation, immunosuppressive therapy post-transplantation, rejection monitoring, and immune tolerance. Studies have shown that immune rejection is a crucial factor affecting the survival rate after organ transplantation. Unlike liver or kidney transplantation, the aim of UTx is to obtain a functional uterus that is able to support successful pregnancy and birth of a healthy fetus. Because of the unique purpose of UTx, its immunosuppressive program is relatively specialized. Some immunosuppressive agents can cause perinatal complications, and inducing immune tolerance is necessary to resolve these side effects. Further understanding of the immune mechanism of UTx and the continuous development of new immunosuppressive agents, combined with the application of assisted reproductive technology, will be more conducive to the realization of UTx to breed offspring.
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Affiliation(s)
- Rui Zhang
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China.
| | - Shou-Long Deng
- CAS Key Laboratory of Genome Sciences and Information, Beijing Institute of Genomics, Chinese Academy of Sciences, 100101 Beijing, China.
| | - Zheng-Xing Lian
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China
| | - Kun Yu
- College of Animal Science and Technology, China Agricultural University, Beijing 100193, China.
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34
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Polić A, Običan SG. Pregnancy in systemic lupus erythematosus. Birth Defects Res 2020; 112:1115-1125. [PMID: 32902202 DOI: 10.1002/bdr2.1790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/05/2020] [Accepted: 07/30/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is a chronic illness that often affects women of reproductive age. The objectives of this article are to review the impact of SLE on pregnancy and current management strategies, including commonly used therapies. METHODS We conducted a review of available literature on the clinical course of SLE, diagnosis, management and pregnancy complications. RESULTS SLE has a variable clinical course characterized by flares and periods of remission and can present unique challenges in the management of obstetric patients. Pregnancy in patients with SLE is associated with multiple risks, including fetal loss, preterm birth, fetal growth restriction, and hypertensive disease. With advancements in disease treatment, many women have favorable pregnancy outcomes, but appropriate preconception counseling and disease management remain important tools in reducing complications. CONCLUSION Given the implications SLE can have on women of reproductive age and in pregnancy, understanding the disease course and management is important in order to optimize pregnancy outcomes.
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Affiliation(s)
- Aleksandra Polić
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Sarah G Običan
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
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Thai TN, Sarayani A, Wang X, Albogami Y, Rasmussen SA, Winterstein AG. Risk of pregnancy loss in patients exposed to mycophenolate compared to azathioprine: A retrospective cohort study. Pharmacoepidemiol Drug Saf 2020; 29:716-724. [PMID: 32347619 DOI: 10.1002/pds.5017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/08/2020] [Accepted: 04/09/2020] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the relative risk of pregnancy loss associated with mycophenolate (MPA) vs azathioprine (AZA) use. METHODS We conducted a retrospective cohort study using the IBM MarketScan Research Databases (2005-2015). Patients with ≥1 MPA or AZA prescription claim during the first trimester were included. The study outcome was pregnancy loss (spontaneous abortion or stillbirth). Potential confounders included age, drug indications, comorbidities, other teratogenic medication use, and gestational age at first MPA or AZA prescription fill. The risk for pregnancy loss was estimated using a generalized estimating equation model with stabilized inverse probability of treatment weighting. In sensitivity analyses, we varied the exposure definition, outcome definition, and the analytical method. RESULTS Among 111 pregnancies exposed to MPA, 55 resulted in pregnancy loss (49.5%). Among 471 pregnancies exposed to AZA, 113 had pregnancy loss (24.0%). The unadjusted relative risk for pregnancy loss was 2.0 (95% CI 1.6, 2.6), and the adjusted relative risk was 1.9 (95% CI, 1.6, 2.3) compared to AZA. Relative risk estimates were stable in all sensitivity analyses. CONCLUSION Exposure to MPA during early pregnancy was associated with a 2-fold increase in pregnancy loss risk.
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Affiliation(s)
- Thuy Nhu Thai
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Faculty of Pharmacy, Ho Chi Minh City University of Technology (HUTECH), Ho Chi Minh City, Vietnam
| | - Amir Sarayani
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Xi Wang
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Yasser Albogami
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, Florida, USA.,Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Sonja A Rasmussen
- Department of Pediatrics, College of Medicine, University of Florida, Gainesville, Florida, USA.,Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
| | - Almut G Winterstein
- Department of Epidemiology, College of Medicine and College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA.,Department of Pharmaceutical Outcomes and Policy, College of Pharmacy and Center for Drug Evaluation and Safety (CoDES), University of Florida, Gainesville, Florida, USA
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36
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Li S, Ren H, Xu Y, Xu T, Zhang Y, Yin H, Zhang W, Li J, Ren X, Fang F, Li W, Zhu Y, Peng B, Wang J, Zhong Y, Cui L. Long-term efficacy of mycophenolate mofetil in myelin oligodendrocyte glycoprotein antibody-associated disorders: A prospective study. NEUROLOGY-NEUROIMMUNOLOGY & NEUROINFLAMMATION 2020; 7:7/3/e705. [PMID: 32170045 PMCID: PMC7136046 DOI: 10.1212/nxi.0000000000000705] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 02/05/2020] [Indexed: 11/22/2022]
Abstract
Objective To investigate whether the use of mycophenolate mofetil (MMF) could reduce the relapse risk in patients with myelin oligodendrocyte glycoprotein (MOG)-immunoglobulin G (IgG)-associated disorders (MOGADs). Methods This prospective observational cohort study included patients with MOGAD at Peking Union Medical College Hospital between January 1, 2017, and April 30, 2019. The patients were divided into 2 groups: those with (MMF+) or without (MMF−) MMF therapy. The primary outcome was relapse at follow-up. We used Cox proportional hazards models to calculate hazard ratios (HRs) for relapse. Results Seventy-nine patients were included in our MOG cohort. Fifty (63.3%) were adults at index date, and 47 (59.5%) were women. Fifty-four (68.4%) were in the MMF+ group, and 25 (31.6%) were in the MMF− group. Clinical and demographic factors, MOG-IgG titer, and follow-up time (median, 472.5 days for MMF+, 261.0 days for MMF−) were comparable between the groups. Relapse rates were 7.4% (4/54) in the MMF+ group and 44.0% (11/25) in the MMF− group. Of all potential confounders, only the use of MMF was associated with reduced risk of relapse. The HR for relapse among patients in the MMF+ group was 0.14 (95% CI, 0.05–0.45) and was 0.08 (95% CI, 0.02–0.28) in a model adjusted for age, sex, disease course, and MOG-IgG titer. MMF therapy also remained associated with a reduced relapse risk in sensitivity analyses. Only one patient (1.9%) discontinued MMF therapy because of adverse effect. Conclusions These findings provide a clinical evidence that MMF immunosuppression therapy may prevent relapse in patients with MOGAD. Classification of evidence This study provides class IV evidence that for patients with MOGAD, MMF reduces relapse risk.
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Affiliation(s)
- Shengde Li
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Haitao Ren
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Yan Xu
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China.
| | - Tao Xu
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China.
| | - Yao Zhang
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Hexiang Yin
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Weihua Zhang
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Jiuwei Li
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaotun Ren
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Fang Fang
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Wenhan Li
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Yicheng Zhu
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Bin Peng
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Jing Wang
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Yong Zhong
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
| | - Liying Cui
- From the Department of Neurology (S.L., H.R., Y.X., Y. Zhang, H.Y., Y. Zhu, B.P., L.C.), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; Department of Epidemiology and Biostatistics Institute of Basic Medical Sciences (T.X.), Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College; Department of Neurology (W.Z., J.L., X.R., F.F.), Beijing Children's Hospital, Capital Medical University, National Center for Children's Health; Oumeng V Medical Laboratory (W.L.), Hangzhou; CAS Key Laboratory of Mental Health (J.W.), Institute of Psychology, Beijing, China Department of Psychology, University of Chinese Academy of Sciences; Department of Ophthalmology (Y. Zhong), Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences; and Neurosciences Center (L.C.), Chinese Academy of Medical Sciences, Beijing, China
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Mao-Draayer Y, Thiel S, Mills EA, Chitnis T, Fabian M, Katz Sand I, Leite MI, Jarius S, Hellwig K. Neuromyelitis optica spectrum disorders and pregnancy: therapeutic considerations. Nat Rev Neurol 2020; 16:154-170. [PMID: 32080393 DOI: 10.1038/s41582-020-0313-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/18/2022]
Abstract
Neuromyelitis optica spectrum disorders (NMOSD) are a type of neurological autoimmune disease characterized by attacks of CNS inflammation that are often severe and predominantly affect the spinal cord and optic nerve. The majority of individuals with NMOSD are women, many of whom are of childbearing age. Although NMOSD are rare, several small retrospective studies and case reports have indicated that pregnancy can worsen disease activity and might contribute to disease onset. NMOSD disease activity seems to negatively affect pregnancy outcomes. Moreover, some of the current NMOSD treatments are known to pose risks to the developing fetus and only limited safety data are available for others. Here, we review published studies regarding the relationship between pregnancy outcomes and NMOSD disease activity. We also assess the risks associated with using disease-modifying therapies for NMOSD during the course of pregnancy and breastfeeding. On the basis of the available evidence, we offer recommendations regarding the use of these therapies in the course of pregnancy planning in individuals with NMOSD.
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Affiliation(s)
- Yang Mao-Draayer
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA.,Graduate Program in Immunology, Program in Biomedical Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Sandra Thiel
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Elizabeth A Mills
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Tanuja Chitnis
- Department of Neurology, Brigham and Women's Hospital and Massachusetts General Hospital, Boston, MA, USA
| | - Michelle Fabian
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ilana Katz Sand
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - M Isabel Leite
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sven Jarius
- Molecular Neuroimmunology Group, Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany.
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Abstract
Many neuromuscular disorders preexist or occur during pregnancy. In some cases, pregnancy unmasks a latent hereditary disorder. Most available information is based on case reports or series or retrospective clinical experience or patient surveys. Of special interest are pregnancy-induced changes in disease course or severity and likelihood for baseline recovery of function postpartum. Labor and delivery present special challenges in many conditions that affect skeletal but not smooth (uterine) muscle; so labor complications must be anticipated. Anesthesia for cesarean section surgery requires special precautions in many disorders. The types of conditions reviewed are broad and include examples of autoimmune, hereditary, and compressive/mechanical processes. Disorders include carpal tunnel syndrome and other focal neuropathies, Bell palsy, myasthenia gravis, and other neuromuscular junction disorders, acute and chronic inflammatory neuropathy, hereditary and acquired muscle diseases, spinal muscular atrophy, amyotrophic lateral sclerosis, channelopathies, autonomic neuropathy, and dysautonomia. Many commonly used therapies have fetal animal but no proven human toxicity concerns, complicating treatment and risk decisions. Weaning off effective therapeutic agents or preemptive aggressive treatment or surgery prior to planned pregnancy is an option in some conditions.
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Affiliation(s)
- Louis H. Weimer
- Correspondence to: Louis H. Weimer, M.D., Neurological Institute of New York, 710 W. 168th Street, New York, NY 10032, United States. Tel: + 1-212-305-1516, Fax: + 1-212-305-4268
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Silva R, Portela R, da Costa I, de Oliveira A, Woods D, de Oliveira C, Fonteles M, Beserra M. Immunosuppressives and enteral feeding tubes: An integrative review. J Clin Pharm Ther 2019; 45:408-418. [PMID: 31854065 DOI: 10.1111/jcpt.13093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/28/2019] [Accepted: 11/18/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Renan Silva
- Multidisciplinary Integrated Residence in Hospital Health Care—Transplant Care University Hospital Walter Cantídio Fortaleza Brazil
| | - Rosana Portela
- Multidisciplinary Integrated Residence in Hospital Health Care—Intensive Care University Hospital Walter Cantídio Fortaleza Brazil
| | - Iwyson da Costa
- Multidisciplinary Integrated Residence in Hospital Health Care—Transplant Care University Hospital Walter Cantídio Fortaleza Brazil
| | - Alene de Oliveira
- Clinical Pharmacy Service University Hospital Walter Cantídio Fortaleza Brazil
| | - David Woods
- School of Pharmacy Otago University Dunedin New Zealand
| | - Cristiani de Oliveira
- Postgraduate Program in Pharmaceutical Sciences Faculty of Pharmacy, Dentistry and Nursing Federal University of Ceará Fortaleza Brazil
| | - Marta Fonteles
- Postgraduate Program in Pharmaceutical Sciences Faculty of Pharmacy, Dentistry and Nursing Federal University of Ceará Fortaleza Brazil
| | - Milena Beserra
- Clinical Pharmacy Service University Hospital Walter Cantídio Fortaleza Brazil
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40
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Affiliation(s)
| | - Joann Norma Bodurtha
- Department of Genetic Medicine.,Departments of Pediatrics and Oncology, Johns Hopkins University School of Medicine, Baltimore, MD
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41
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Altıntaş Aykan D, Ergün Y. Klinik farmakoloji teratoloji risk analizi ile gebelikte kardiyovasküler ilaç kullanımının güvenilirliği. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.490997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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42
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Maynard S, Guerrier G, Duffy M. Pregnancy in Women With Systemic Lupus and Lupus Nephritis. Adv Chronic Kidney Dis 2019; 26:330-337. [PMID: 31733717 DOI: 10.1053/j.ackd.2019.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 07/12/2019] [Accepted: 08/19/2019] [Indexed: 11/11/2022]
Abstract
Pregnancy is an altered immunologic state in which hormonal changes impact the immune system to enable maternal tolerance of the fetus. These hormonal and immunologic changes may affect disease activity in systemic lupus erythematosus. Conversely, lupus nephritis and its complications may adversely impact pregnancy. Systemic lupus erythematosus increases the risk of pre-eclampsia and its complications, including preterm birth and intrauterine growth restriction. Comorbidities such as impaired kidney function and hypertension confer additional risk and complexity. Medications used to treat lupus nephritis may impact the fetus, so therapy needs to be tailored to balance maternal benefit and fetal risk. The diagnosis of lupus nephritis during pregnancy can be difficult, as it shares overlapping features with pre-eclampsia. Kidney biopsy is generally safe in pregnancy, and should be considered if the result will affect management. Here we review the clinical aspects of counseling, diagnosis, and management of lupus nephritis in pregnancy.
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Jones BP, Saso S, Bracewell-Milnes T, Thum MY, Nicopoullos J, Diaz-Garcia C, Friend P, Ghaem-Maghami S, Testa G, Johannesson L, Quiroga I, Yazbek J, Smith JR. Human uterine transplantation: a review of outcomes from the first 45 cases. BJOG 2019; 126:1310-1319. [PMID: 31410987 DOI: 10.1111/1471-0528.15863] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2019] [Indexed: 12/20/2022]
Abstract
Uterine transplantation restores reproductive anatomy in women with absolute uterine factor infertility and allows the opportunity to conceive, experience gestation, and acquire motherhood. The number of cases being performed is increasing exponentially, with detailed outcomes from 45 cases, including nine live births, now available. In light of the data presented herein, including detailed surgical, immunosuppressive and obstetric outcomes, the feasibility of uterine transplantation is now difficult to refute. However, it is associated with significant risk with more than one-quarter of grafts removed because of complications, and one in ten donors suffering complications requiring surgical repair. TWEETABLE ABSTRACT: Uterine transplantation is feasible in women with uterine factor infertility, but is associated with significant risk of complication.
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Affiliation(s)
- B P Jones
- Hammersmith Hospital, Imperial College NHS Trust London, London, UK.,Imperial College London, London, UK.,Lister Fertility Clinic, The Lister Hospital, London, UK
| | - S Saso
- Hammersmith Hospital, Imperial College NHS Trust London, London, UK.,Imperial College London, London, UK
| | - T Bracewell-Milnes
- Imperial College London, London, UK.,Lister Fertility Clinic, The Lister Hospital, London, UK
| | - M-Y Thum
- Imperial College London, London, UK.,Lister Fertility Clinic, The Lister Hospital, London, UK
| | - J Nicopoullos
- Imperial College London, London, UK.,Lister Fertility Clinic, The Lister Hospital, London, UK
| | - C Diaz-Garcia
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK.,IVI London, IVIRMA Global, London, UK
| | - P Friend
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK.,Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - S Ghaem-Maghami
- Hammersmith Hospital, Imperial College NHS Trust London, London, UK.,Imperial College London, London, UK
| | - G Testa
- Baylor University Medical Center, Dallas, TX, USA
| | | | - I Quiroga
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Yazbek
- Hammersmith Hospital, Imperial College NHS Trust London, London, UK.,Imperial College London, London, UK
| | - J R Smith
- Hammersmith Hospital, Imperial College NHS Trust London, London, UK.,Imperial College London, London, UK
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Jones BP, Saso S, L'Heveder A, Bracewell-Milnes T, Thum MY, Diaz-Garcia C, MacIntyre DA, Quiroga I, Ghaem-Maghami S, Testa G, Johannesson L, Bennett PR, Yazbek J, Smith JR. The vaginal microbiome in uterine transplantation. BJOG 2019; 127:230-238. [PMID: 31397072 DOI: 10.1111/1471-0528.15881] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2019] [Indexed: 12/20/2022]
Abstract
Women with congenital absolute uterine factor infertility (AUFI) often need vaginal restoration to optimise sexual function. Given their lack of procreative ability, little consideration has previously been given to the resultant vaginal microbiome (VM). Uterine transplantation (UTx) now offers the opportunity to restore these women's reproductive potential. The structure of the VM is associated with clinical and reproductive implications that are intricately intertwined with the process of UTx. Consideration of how vaginal restoration methods impact VM is now warranted and assessment of the VM in future UTx procedures is essential to understand the interrelation of the VM and clinical and reproductive outcomes. TWEETABLE ABSTRACT: The vaginal microbiome has numerous implications for clinical and reproductive outcomes in the context of uterine transplantation.
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Affiliation(s)
- B P Jones
- Hammersmith Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK.,Lister Fertility Clinic, The Lister Hospital, London, UK
| | - S Saso
- Hammersmith Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - A L'Heveder
- Hammersmith Hospital, Imperial College NHS Trust, London, UK
| | - T Bracewell-Milnes
- Department of Surgery and Cancer, Imperial College London, London, UK.,Lister Fertility Clinic, The Lister Hospital, London, UK
| | - M-Y Thum
- Department of Surgery and Cancer, Imperial College London, London, UK.,Lister Fertility Clinic, The Lister Hospital, London, UK
| | - C Diaz-Garcia
- IVI London, IVIRMA Global, London, UK.,Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - D A MacIntyre
- Department of Surgery and Cancer, Imperial College London, London, UK.,March of Dimes European Preterm Birth Research Centre, Imperial College London, London, UK
| | - I Quiroga
- The Oxford Transplant Centre, The Churchill Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - S Ghaem-Maghami
- Hammersmith Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - G Testa
- Baylor University Medical Centre, Dallas, TX, USA
| | | | - P R Bennett
- Hammersmith Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK.,March of Dimes European Preterm Birth Research Centre, Imperial College London, London, UK
| | - J Yazbek
- Hammersmith Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
| | - J R Smith
- Hammersmith Hospital, Imperial College NHS Trust, London, UK.,Department of Surgery and Cancer, Imperial College London, London, UK
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45
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A New Life: Motherhood After Heart Transplantation. A Single-center Experience and Review of Literature. Transplantation 2019; 102:1538-1544. [PMID: 29762460 DOI: 10.1097/tp.0000000000002281] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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46
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Ingolotti M, Schlaen BA, Roig Melo-Granados EA, Ruiz García H, Aguilera Partida JA. Azathioprine During the First Trimester of Pregnancy in a Patient with Vogt-Koyanagi-Harada Disease: A Multimodal Imaging Follow-Up Study. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:300-305. [PMID: 30842390 PMCID: PMC6419529 DOI: 10.12659/ajcr.914281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patient: Female, 27 Final Diagnosis: Vogt Koyanagi Harada Disease Symptoms: Headache • vision loss Medication: — Clinical Procedure: — Specialty: Ophthalmology
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Affiliation(s)
- Mariana Ingolotti
- Department of Ophthalmology, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | - Bernardo A Schlaen
- Department of Ophthalmology, Hospital Universitario Austral, Buenos Aires, Argentina
| | - Enrique Alfonso Roig Melo-Granados
- Department of Ophthalmology, Hospital Civil Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico.,Clínica Oftalmológica (Ophthalmological Clinic) Santa Lucía, Guadalajara, Jalisco, Mexico
| | - Humberto Ruiz García
- Clínica Oftalmológica (Ophthalmological Clinic) Santa Lucía, Guadalajara, Jalisco, Mexico
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Sokal A, Elefant E, Leturcq T, Beghin D, Mariette X, Seror R. Pregnancy and newborn outcomes after exposure to bisphosphonates: a case-control study. Osteoporos Int 2019; 30:221-229. [PMID: 30171300 DOI: 10.1007/s00198-018-4672-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 08/13/2018] [Indexed: 01/13/2023]
Abstract
UNLABELLED We analyzed women and newborn outcome after maternal exposure to BPs. BPs have no teratogenic effect on the 36 analyzed pregnancies compared to unexposed controls matched on women underlying diseases (either systemic disease, either "bone" disease) but some outcome differed: neonatal complications rate in systemic diseases and live birth rate in bone diseases). INTRODUCTION The effect of bisphosphonates (BPs) during pregnancy remains unclear. We aimed to study pregnancy outcomes in women exposed to BPs during pregnancy. METHODS Data for cases and controls were from the French Reference Centre of Teratogenic Agents. Cases were women who received BPs in the 6 weeks before or during a pregnancy and had systemic or bone diseases. We included two respectively matched control groups: women with systemic diseases not exposed to BPs and healthy women not exposed to BPs or any teratogenic agent. Four controls were assigned to each case. RESULTS Thirty-six women were exposed to BPs including 5 just before pregnancy and 30 during the first trimester; 23 had systemic diseases (systemic lupus erythematosus, n = 5; rheumatoid arthritis, n = 5; other, n = 13) and 13 had bone diseases. Rate of observed congenital malformations did not differ in women with a systemic or a bone disease compared to their respective controls (respectively 2/23 [8.7%] vs 2/92 [2.2%], p = 0.178 and 0/13 [0%] vs 0/52 [0%], p = 1.00). Among women with systemic diseases, non-specific neonatal complications were more frequent for cases (4/16 [25.0%] vs 4/64 [6.3%], p = 0.027). Among women with bone disorders, the live birth rate was lower for cases than healthy controls (8/10 [80%] vs 50/50 [100%], p = 0.025). CONCLUSION We found no major teratogenic effects of BPs, but rates of neonatal complications were increased for women with systemic diseases, as were spontaneous abortions for women with bone diseases likely linked to the severity of the underlying diseases and concomitant medications.
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Affiliation(s)
- A Sokal
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Department of Rheumatology, Hôpital Bicêtre Université Paris-Sud, INSERM U1184, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - E Elefant
- Centre de Référence sur les Agents Tératogènes (CRAT), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Est Parisien - Pôle Périnatalité - Hôpital Armand Trousseau, 26, av Dr Netter, 75571, Paris cedex 12, France
| | - T Leturcq
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Department of Rheumatology, Hôpital Bicêtre Université Paris-Sud, INSERM U1184, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - D Beghin
- Centre de Référence sur les Agents Tératogènes (CRAT), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Est Parisien - Pôle Périnatalité - Hôpital Armand Trousseau, 26, av Dr Netter, 75571, Paris cedex 12, France
| | - X Mariette
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Department of Rheumatology, Hôpital Bicêtre Université Paris-Sud, INSERM U1184, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France
| | - R Seror
- Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Department of Rheumatology, Hôpital Bicêtre Université Paris-Sud, INSERM U1184, 78 rue du Général Leclerc, 94275, Le Kremlin Bicêtre, France.
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Mycophenolate mofetil for sustained remission in nephrotic syndrome. Pediatr Nephrol 2018; 33:2253-2265. [PMID: 29750317 DOI: 10.1007/s00467-018-3970-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 04/13/2018] [Accepted: 04/17/2018] [Indexed: 10/16/2022]
Abstract
The clinical application of mycophenolate mofetil (MMF) has significantly widened beyond the prophylaxis of acute and chronic rejections in solid organ transplantation. MMF has been recognized as an excellent treatment option in many immunologic glomerulopathies. For children with frequently relapsing nephrotic syndrome (FRNS) or steroid-dependent nephrotic syndrome (SDNS) experiencing steroid toxicity, MMF has been recommended as a steroid-sparing drug. Uncontrolled studies in patients with FRNS and SDSN have shown that many patients can achieve sustained remission of proteinuria with MMF monotherapy. Three randomized controlled trials have similarly demonstrated that MMF is beneficial in these patients, but less effective than the calcineurin inhibitors cyclosporin A or tacrolimus. Some, but not all, patients with steroid-resistant nephrotic syndrome (SRNS) may also respond to MMF, usually given in combination with other drugs, with partial or complete remission. There are important limitations to the interpretation and comparability of these studies including study design, sample size, patient selection, clinical endpoints, carry-over effects, and duration of follow-up. In all studies, MMF had relatively few side effects, no nephrotoxicity, or no systemic toxicity. MMF is teratogenic, and contraceptive advice is required in females. There is a poor correlation between MMF dose and mycophenolic acid (MPA) exposure and significant inter- and intra-patient variability in drug pharmacokinetics. A higher estimated MPA-AUC0-12 target range than recommended for pediatric renal transplant recipients is essential to prevent relapses. Therefore, therapy should be guided by drug monitoring to avoid relapses. Further studies are needed to test the efficacy of MMF in inducing remission and, as part of a combination therapy, achieving sustained remission in patients with SRNS.
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Hiramatsu Y, Yoshida S, Kotani T, Nakamura E, Kimura Y, Fujita D, Nagayasu Y, Shabana K, Makino S, Takeuchi T, Arawaka S. Changes in the blood level, efficacy, and safety of tacrolimus in pregnancy and the lactation period in patients with systemic lupus erythematosus. Lupus 2018; 27:2245-2252. [PMID: 30394835 DOI: 10.1177/0961203318809178] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We investigated the efficacy and safety of tacrolimus (TAC) by monitoring its serum concentration for mothers and infants in pregnant patients with systemic lupus erythematosus (SLE). METHODS We measured trough concentrations of TAC in 25 pregnant patients with SLE to assess influence of TAC on the disease activity. Additionally, we measured the concentrations of TAC in umbilical arterial blood, breast milk, and breastfed infants to investigate the safety of TAC for the mothers and infants. RESULTS The trough concentrations of TAC in the mothers significantly decreased in the second trimester as compared with those before pregnancy. However, the decrease in the trough concentrations of TAC did not lead to the deterioration of SLE. When examined, the doses of TAC were significantly lower in the second trimester and postpartum in the deteriorating group than those in the non-deteriorating group. There were no adverse events by TAC in mothers and fetuses. The concentrations of TAC in the umbilical cord blood were lower than those in the maternal blood. The relative infant dose in breastfed infants of TAC was < 1%. The level of TAC in infant bloods was below detectable limits. CONCLUSION These findings suggest that TAC is one of the most effective and safest immunosuppressive drugs for use in pregnant patients with SLE.
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Affiliation(s)
- Y Hiramatsu
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - S Yoshida
- 2 Department of Internal Medicine, Arisawa General Hospital, Osaka, Japan
| | - T Kotani
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - E Nakamura
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - Y Kimura
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - D Fujita
- 3 Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - Y Nagayasu
- 3 Department of Obstetrics and Gynecology, Osaka Medical College, Osaka, Japan
| | - K Shabana
- 4 Department of Pediatrics, Osaka Medical College, Osaka, Japan
| | - S Makino
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - T Takeuchi
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
| | - S Arawaka
- 1 Department of Internal Medicine (IV), Osaka Medical College, Osaka, Japan
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50
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Cabiddu G, Spotti D, Gernone G, Santoro D, Moroni G, Gregorini G, Giacchino F, Attini R, Limardo M, Gammaro L, Todros T, Piccoli GB. 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. J Nephrol 2018; 31:665-681. [PMID: 29949013 PMCID: PMC6182355 DOI: 10.1007/s40620-018-0499-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/30/2018] [Indexed: 12/15/2022]
Abstract
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".
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Affiliation(s)
| | | | | | | | | | | | | | | | - Monica Limardo
- Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | | | - Tullia Todros
- Department of Surgery, Università di Torino, Turin, Italy
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, Università di Torino, Turin, Italy.
- Centre Hospitalier Le Mans, Le Mans, France.
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