Renal function and lipid metabolism in pregnant renal transplant recipients

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

Approximately 50,000 women of reproductive age in the United States are currently living after kidney transplantation (KT), and another 2800 undergo KT each year. Although KT improves reproductive function in women with ESRD, studies of post-KT pregnancies are limited to a few voluntary registry analyses and numerous single-center reports. To obtain more generalizable inferences, we performed a systematic review and meta-analysis of articles published between 2000 and 2010 that reported pregnancy-related outcomes among KT recipients. Of 1343 unique studies, 50 met inclusion criteria, representing 4706 pregnancies in 3570 KT recipients. The overall post-KT live birth rate of 73.5% (95%CI 72.1-74.9) was higher than the general US population (66.7%); similarly, the overall post-KT miscarriage rate of 14.0% (95%CI 12.9-15.1) was lower (17.1%). However, complications of preeclampsia (27.0%, 95%CI 25.2-28.9), gestational diabetes (8.0%, 95%CI 6.7-9.4), Cesarean section (56.9%, 95%CI 54.9-58.9) and preterm delivery (45.6%, 95%CI 43.7-47.5) were higher than the general US population (3.8%, 3.9%, 31.9% and 12.5%, respectively). Pregnancy outcomes were more favorable in studies with lower mean maternal ages; obstetrical complications were higher in studies with shorter mean interval between KT and pregnancy. Although post-KT pregnancy is feasible, complications are relatively high and should be considered in patient counseling and clinical decision making.

Pregnancy after transplantation

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

Beneficial effect of dl-α-lipoic acid on cyclosporine A induced hyperlipidemic nephropathy in rats

Cyclosporine A (CsA)-induced dyslipidemia is one of the most important risk factors for morbidity and mortality after solid organ transplantation. Reducing this side effect of CsA by dietary agents may be safe, cost-effective, and attractive to both patients and health professionals. Hence the present study was designed to evaluate the role of DL-alpha-Lipoic acid (LA) in deteriorating the lipid abnormalities induced by CsA in rat kidney. Male albino Wistar rats were divided into four groups. CsA administered at a dose of 25 mg/kg body weight, orally for 21 days showed abnormal changes in the levels of lipoprotein fractions (LDL, HDL and VLDL) and lipid profile in both plasma and renal tissue. Significant alterations were also observed in the activities of lipid metabolizing enzymes. Co-treatment with LA (20 mg/kg body weight, oral gavage, for 21 days) reverted the levels of lipid profile (P < 0.001, P < 0.01) and lipoprotein fractions (P < 0.001, P < 0.01) to near control. The activities of lipid metabolizing enzymes also showed considerable restoration on LA supplementation. The outcome of this study provides evidence that LA (a natural metabolic antioxidant) treatment acts as a potent antilipemic agent against CsA-induced lipid abnormalities.

Cyclosporin-A augments respiratory burst of whole blood phagocytes in pregnant rats

Both pregnancy and cyclosporin A (CsA) are known to inhibit T-cell mediated immune response and to activate phagocytes against microbial infections as a compensatory mechanism. Pregnant women, either with organ transplantation or suffering from autoimmune diseases, are commonly managed with CsA therapy. This investigation was aimed to study effect of CsA on phagocytic activity of whole blood polymorphonuclear leukocytes (PMNs) in pregnant rats. Both pregnant and non-pregnant Sprague-Dawley rats (4 animals per group) were treated with CsA (40 mg/kg, oral) for 7 days starting from gestation day 7. Respective control groups of non-pregnant and pregnant rats received vehicle only. Luminol-dependent chemiluminescence (CL) was used to measure the generation of reactive oxygen species (ROS) in respiratory burst of whole blood PMNs stimulated by zymosan. The results showed a moderate and insignificant increase in CL response in non-pregnant rats with CsA treatment or pregnant rats without CsA treatment. Whereas the CL response of whole blood PMNs was significantly higher (ANOVA F = 35.66, P < 0.001) in pregnant rats treated with CsA. In conclusion, this preliminary study demonstrates synergistic effects of pregnancy and CsA on activation of PMNs resulting in massive and sustained generation of ROS that could be deleterious to both host and fetus.

Pregnancy in patients with previous successful renal transplantation

OBJECTIVE

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

METHOD

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

RESULT

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

CONCLUSION

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