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Gupta M, Yadav A. Reproductive Health in Kidney Transplant Recipients. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:466-475. [PMID: 39232617 DOI: 10.1053/j.akdh.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/15/2024] [Accepted: 04/24/2024] [Indexed: 09/06/2024]
Abstract
Increasing number of women with kidney transplants are of reproductive age and desire successful pregnancies. Successful outcomes of pregnancy can be achieved with preconception counseling, education about contraception use, the timing of pregnancy (delaying by first year post-transplant), and the choice of immunosuppression medication. Ensuring stable renal function including optimized creatinine, proteinuria, and blood pressure increases successful outcomes. Pregnancy with kidney transplant has an increased risk of preeclampsia, gestational diabetes militeus, cesarean section, and preterm delivery. Multidisciplinary cooperation with high-risk obstetrics and transplant nephrologists is vital.
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Affiliation(s)
- Maitreyee Gupta
- Division of Nephrology and Transplantation, Sidney Kimmel Medical School with Thomas Jefferson University, Philadelphia, PA.
| | - Anju Yadav
- Division of Nephrology and Transplantation, Sidney Kimmel Medical School with Thomas Jefferson University, Philadelphia, PA
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Rondeau E, Ardissino G, Caby-Tosi MP, Al-Dakkak I, Fakhouri F, Miller B, Scully M. Pregnancy in Women with Atypical Hemolytic Uremic Syndrome. Nephron Clin Pract 2021; 146:1-10. [PMID: 34515154 DOI: 10.1159/000518171] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 06/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pregnancy outcomes in patients with atypical hemolytic uremic syndrome (aHUS) are not well-documented. Here, we present characteristics of and outcomes for patients with aHUS who became pregnant while enrolled in the Global aHUS Registry. METHODS The observational Global aHUS Registry (NCT01522183), initiated in April 2012, collects demographics, disease history, treatment, and outcomes data for patients with aHUS, regardless of treatment approach. This descriptive analysis includes patients from the Registry with evaluable pregnancy data supplemented with pharmacovigilance information; the number of pregnancies, outcomes, and exposure to eculizumab were evaluated. RESULTS As of April 1, 2019, 44 pregnancies were recorded in 41 patients, with 24 pregnancies exposed to eculizumab. Pathogenic variants were identified in 48.8% of patients. Three patients were on dialysis and 6 patients had a kidney graft at the time of pregnancy. Excluding elective terminations, 85.3% of pregnancies resulted in live births. Elective terminations were recorded in 22.7% of pregnancies, miscarriages occurred in 9.1% of pregnancies, and late fetal death in 2.3% of pregnancies. No malformations or anomalies were reported. CONCLUSIONS Our results show that in women with aHUS, even on dialysis or with a kidney graft, pregnancy is possible with careful monitoring for aHUS flares and prematurity. Prophylactic or therapeutic eculizumab offers disease control with low-risk of fetal abnormalities.
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Affiliation(s)
- Eric Rondeau
- Intensive Care Nephrology and Transplantation Department, Hôpital Tenon, APHP, Sorbonne Université, Paris, France
| | - Gianluigi Ardissino
- Centro per la Cura e lo Studio della Sindrome Emolitico-Uremica, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Imad Al-Dakkak
- Epidemiology, Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Service de Néphrologie et Immunologie Clinique, CHU de Nantes - Hôtel Dieu, Nantes, France
| | - Benjamin Miller
- Employee at the Time of Study, of Alexion Pharmaceuticals, Inc., Boston, Massachusetts, USA
| | - Marie Scully
- Department of Haematology, University College London Hospital, Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, United Kingdom
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Liu J, Memon AA, Lyu L, Siedlecki A. Comment on "Pharmacology, Pharmacokinetics and Pharmacodynamics of Eculizumab, and Possibilities for an Individualized Approach to Eculizumab". Clin Pharmacokinet 2020; 59:1641-1643. [PMID: 33118149 DOI: 10.1007/s40262-020-00950-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Jialing Liu
- Brigham and Women's Hospital, Boston, MA, USA
- Guangzhou University of Chinese Medicine, The Second Affiliated Hospital of Chinese Medicine, Guangzhou, China
| | | | - Lingna Lyu
- Brigham and Women's Hospital, Boston, MA, USA
- Beijing Chest Hospital, Capital Medical University, Beijing, China
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Abstract
PURPOSE OF REVIEW Pregnancy-related acute kidney injury (Pr-AKI) is associated with increased maternal and fetal morbidity and mortality and remains a large public health problem. RECENT FINDINGS Pr-AKI incidence has globally decreased over time for the most part. However, the cause presents a disparity between developing and developed countries, reflecting differences in socioeconomic factors and healthcare infrastructure - with the noteworthy outlier of increased incidence in the United States and Canada. Although Pr-AKI can be secondary to conditions affecting the general population, in most cases it is pregnancy specific. Septic abortion, hyperemesis gravidarum, and hemorrhage have become less prevalent with access to healthcare but are being displaced by thrombotic microangiopathies, such as preeclampsia, hemolysis, elevated liver enzymes, low platelets syndrome, thrombotic thrombocytopenic purpura, and pregnancy-associated hemolytic-uremic syndromes, as well as acute fatty liver of pregnancy. Understanding these conditions plays a pivotal role in the timely diagnosis and enhancement of therapeutic approaches. SUMMARY In this review, we focus on the renal physiology of the pregnancy, epidemiology, and specific conditions known to cause Pr-AKI, summarizing diagnostic definition, insights in pathophysiology, clinical considerations, and novel treatment approaches, thus providing the reader a framework of clinically relevant information for interdisciplinary management.
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Amari Chinchilla K, Vijayan M, Taveras Garcia B, Jim B. Complement-Mediated Disorders in Pregnancy. Adv Chronic Kidney Dis 2020; 27:155-164. [PMID: 32553248 DOI: 10.1053/j.ackd.2020.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 12/13/2022]
Abstract
Complement-mediated disorders in pregnancy span a large spectrum and have been implicated in all three complement pathways: classical, lectin, and alternative. Our understanding of these disorders in recent years has advanced due to a better understanding of complement regulatory proteins, such as complement factor H, complement factor I, membrane cofactor protein, and thrombomodulin that particularly affect the alternative complement pathway. Enthusiasm in genotyping for mutations that encode these proteins has allowed us to study the presence of genetic variants which may predispose women to develop conditions such as pregnancy-associated hemolytic uremic syndrome (P-aHUS), thrombotic thrombocytopenic purpura, preeclampsia/hemolysis, elevated liver enzymes, low platelets (HELLP), systemic lupus erythematosus/antiphospholipid syndrome, and peripartum cardiomyopathy. The advent of the anti-C5-antibody eculizumab to quench the complement cascade has already proven in small case series to improve maternal kidney outcomes in complement-mediated obstetric catastrophes such as P-aHUS and HELLP. In this review, we will detail the pathogenesis behind these complement-mediated pregnancy disorders, the role of complement variants in disease phenotype, and the most up-to-date experience with eculizumab in this population.
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Haninger-Vacariu N, Aigner C, Kain R, Prohászka Z, Gaggl M, Böhmig GA, Piggott LC, Sunder-Plassmann R, Sunder-Plassmann G, Schmidt A. Successful Pregnancies During Ongoing Eculizumab Therapy in Two Patients With Complement-Mediated Thrombotic Microangiopathy. Kidney Med 2020; 2:213-217. [PMID: 32734241 PMCID: PMC7380370 DOI: 10.1016/j.xkme.2019.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In patients with pregnancy-associated complement gene variant-mediated thrombotic microangiopathy (cTMA), terminal complement blockade is used for treatment of cTMA flares during pregnancy or following delivery. We report pregnancy and delivery outcomes of 2 genetically high-risk patients with cTMA, including 1 kidney transplant recipient, during ongoing eculizumab therapy. In both patients, the first manifestation of cTMA occurred independent from pregnancy. One patient has a history of 2 uneventful pregnancies with prophylactic plasma infusions, and the other has a history of early abortion during long-term eculizumab therapy following kidney transplantation. Overall, pregnancy and delivery outcomes under ongoing eculizumab therapy in our 2 patients with preserved kidney function were excellent as compared with other patients reported in the literature. Eculizumab plasma concentrations were maintained in the therapeutic range during pregnancy and were also detectable in cord blood. Results of cord blood analysis showed deficient complement activity, with low factor and regulator levels, most likely reflecting the age of the neonates and presence of eculizumab in cord blood. In conclusion, pregnancy during ongoing eculizumab treatment appeared to be safe in 2 women with a history of high-risk genetic cTMA and excellent kidney function, even following kidney transplantation.
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Affiliation(s)
- Natalja Haninger-Vacariu
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christof Aigner
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Zoltán Prohászka
- Research Laboratory, 3rd Department of Internal Medicine, and MTA-SE Research Group of Immunology and Hematology, Hungarian Academy of Sciences and Semmelweis University, Budapest, Hungary
| | - Martina Gaggl
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg A Böhmig
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Leah Charlotte Piggott
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Raute Sunder-Plassmann
- Genetics Laboratory, Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Gere Sunder-Plassmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alice Schmidt
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University of Vienna, Vienna, Austria
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Duval A, Moulin B, Caillard S. The Authors Reply. Kidney Int Rep 2019; 4:1658-1659. [PMID: 31891012 PMCID: PMC6933457 DOI: 10.1016/j.ekir.2019.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 09/02/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Anna Duval
- Department of Nephrology and Transplantation, Strasbourg University Hospital, University of Strasbourg, Strasbourg, France
| | - Bruno Moulin
- Department of Nephrology and Transplantation, Strasbourg University Hospital, University of Strasbourg, Strasbourg, France
- Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg, University of Strasbourg, Strasbourg, France
| | - Sophie Caillard
- Department of Nephrology and Transplantation, Strasbourg University Hospital, University of Strasbourg, Strasbourg, France
- Inserm UMR S1109, LabEx Transplantex, Fédération de Médecine Translationnelle de Strasbourg, University of Strasbourg, Strasbourg, France
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Fontana F, Alfano G, Bardhushi E, Ligabue G, Giovanella S, Neri I, Cappelli G. Relapse of Atypical Hemolytic Uremic Syndrome During Pregnancy in a Patient on Eculizumab Maintenance Treatment: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:1460-1465. [PMID: 31582717 PMCID: PMC6788481 DOI: 10.12659/ajcr.916994] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Female, 28 Final Diagnosis: Relapse of atypical hemolytic uremic syndrome during pregnancy Symptoms: Anemia • edema • hemolysis • oliguria Medication: — Clinical Procedure: — Specialty: Nephrology
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Affiliation(s)
- Francesco Fontana
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Gaetano Alfano
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Ermelinda Bardhushi
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Ligabue
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Giovanella
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
| | - Isabella Neri
- Department of Mother-Infant, University of Modena and Reggio Emilia, Modena, Italy
| | - Gianni Cappelli
- Surgical, Medical and Dental Department of Morphological Sciences, Section of Nephrology, University of Modena and Reggio Emilia, Modena, Italy
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Use of Eculizumab During Pregnancy in Kidney Transplant Recipients With Atypical HUS. Kidney Int Rep 2019; 4:1658. [PMID: 31891011 PMCID: PMC6933456 DOI: 10.1016/j.ekir.2019.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/12/2019] [Indexed: 11/24/2022] Open
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