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Li MY, Shen HH, Cao XY, Gao XX, Xu FY, Ha SY, Sun JS, Liu SP, Xie F, Li MQ. Targeting a mTOR/autophagy axis: a double-edged sword of rapamycin in spontaneous miscarriage. Biomed Pharmacother 2024; 177:116976. [PMID: 38906022 DOI: 10.1016/j.biopha.2024.116976] [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: 03/29/2024] [Revised: 06/02/2024] [Accepted: 06/15/2024] [Indexed: 06/23/2024] Open
Abstract
Immune dysfunction is a primary culprit behind spontaneous miscarriage (SM). To address this, immunosuppressive agents have emerged as a novel class of tocolytic drugs, modulating the maternal immune system's tolerance towards the embryo. Rapamycin (PubChem CID:5284616), a dual-purpose compound, functions as an immunosuppressive agent and triggers autophagy by targeting the mTOR pathway. Its efficacy in treating SM has garnered significant research interest in recent times. Autophagy, the cellular process of self-degradation and recycling, plays a pivotal role in numerous health conditions. Research indicates that autophagy is integral to endometrial decidualization, trophoblast invasion, and the proper functioning of decidual immune cells during a healthy pregnancy. Yet, in cases of SM, there is a dysregulation of the mTOR/autophagy axis in decidual stromal cells or immune cells at the maternal-fetal interface. Both in vitro and in vivo studies have highlighted the potential benefits of low-dose rapamycin in managing SM. However, given mTOR's critical role in energy metabolism, inhibiting it could potentially harm the pregnancy. Moreover, while low-dose rapamycin has been deemed safe for treating recurrent implant failure, its potential teratogenic effects remain uncertain due to insufficient data. In summary, rapamycin represents a double-edged sword in the treatment of SM, balancing its impact on autophagy and immune regulation. Further investigation is warranted to fully understand its implications.
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Affiliation(s)
- Meng-Ying Li
- Institute of Obstetrics and Gynecology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, People's Republic of China
| | - Hui-Hui Shen
- Institute of Obstetrics and Gynecology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, People's Republic of China
| | - Xiao-Yan Cao
- Institute of Obstetrics and Gynecology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, People's Republic of China
| | - Xiao-Xiao Gao
- Department of Obstetrics and Gynecology, Jinshan Hospital, Fudan University, Shanghai 201508, People's Republic of China
| | - Feng-Yuan Xu
- Department of Bioengineering, University of Illinois Urbana-Champaign, Urbana, IL 61801, United States
| | - Si-Yao Ha
- Department of Obstetrics and Gynecology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510235, China
| | - Jian-Song Sun
- School of Life Science and Health Engineering, Jiangnan University, Wuxi 214122, People's Republic of China
| | - Song-Ping Liu
- Department of Obstetrics and Gynecology, Jinshan Hospital, Fudan University, Shanghai 201508, People's Republic of China.
| | - Feng Xie
- Institute of Obstetrics and Gynecology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, People's Republic of China; Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Shanghai Medical School, Fudan University, Shanghai 200080, People's Republic of China.
| | - Ming-Qing Li
- Institute of Obstetrics and Gynecology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, People's Republic of China; Department of Gynecologic Endocrinology and Reproductive Immunology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200030, People's Republic of China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai 200030, People's Republic of China.
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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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Ginda T, Taradaj K, Tronina O, Stelmaszczyk-Emmel A, Kociszewska-Najman B. Evaluation of the Development of Post-Vaccination Immunity against Selected Bacterial Diseases in Children of Post-Solid-Organ-Transplant Mothers. Vaccines (Basel) 2024; 12:565. [PMID: 38932294 PMCID: PMC11209350 DOI: 10.3390/vaccines12060565] [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: 04/30/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024] Open
Abstract
Pregnancy after organ transplantation is considered high-risk and requires supervision in specialized centers. The impact of immunosuppression on the developing fetus is still the subject of research. It has been shown that it affects lymphocyte populations in the first year of life. For this reason, researchers suggest postponing mandatory infant vaccinations. The aim of the study was to analyze the influence of intrauterine exposure of the fetus to immunosuppression on the immunogenicity of protective vaccinations against selected bacterial pathogens. The ELISA method was used to determine the concentration of post-vaccination IgG antibodies against diphtheria, tetanus, pertussis, tuberculosis, H. influenzae type B, and S. pneumoniae in 18 children of mothers who underwent organ transplantation. The results were compared with the control group (n = 21). A comparison of the incidence of adverse post-vaccination reactions between the analyzed groups was also performed. There were no statistically significant differences in the immunogenicity of the analyzed vaccines between children of mothers who underwent organ transplantation and the age-matched general pediatric population. There were no differences in the incidence of adverse post-vaccination reactions between the analyzed groups. The obtained results do not indicate the need to modify the current protective vaccination schemes against bacterial pathogens in children of mothers who underwent organ transplantation.
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Affiliation(s)
- Tomasz Ginda
- Department of Neonatology and Rare Diseases, Faculty of Health Sciences, Medical University of Warsaw, 02-091 Warsaw, Poland; (T.G.); (B.K.-N.)
| | - Karol Taradaj
- Department of Neonatology and Rare Diseases, Faculty of Health Sciences, Medical University of Warsaw, 02-091 Warsaw, Poland; (T.G.); (B.K.-N.)
| | - Olga Tronina
- Poland Department of Transplantation Medicine, Nephrology and Internal Diseases, Faculty of Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Anna Stelmaszczyk-Emmel
- Department of Laboratory Diagnostics and Clinical Immunology of Developmental Age, Faculty of Medicine, Medical University of Warsaw, 02-091 Warsaw, Poland
| | - Bożena Kociszewska-Najman
- Department of Neonatology and Rare Diseases, Faculty of Health Sciences, Medical University of Warsaw, 02-091 Warsaw, Poland; (T.G.); (B.K.-N.)
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Jha N, Jha AK, Mishra SK, Parida S. Thoracic organ transplantation and pregnancy outcomes: systematic review and meta-analysis. Arch Gynecol Obstet 2024; 309:385-396. [PMID: 37147484 DOI: 10.1007/s00404-023-07065-x] [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: 10/11/2022] [Accepted: 05/01/2023] [Indexed: 05/07/2023]
Abstract
PURPOSE Pre-conceptual comorbidities, an inherent risk of graft loss, rejection during pregnancy, and the postpartum period in women with thoracic lung transplant may predispose them to increased risk of adverse feto-maternal outcomes. The study aimed to systematically analyze and assess the risk of adverse pregnancy outcomes in women with thoracic organ transplant. METHODS MEDLINE, EMBASE, and Cochrane library were searched for publication between January 1990 and June 2020. Risk of bias was assessed using Joanna Briggs critical appraisal tool for case series. The primary outcomes included maternal mortality and pregnancy loss. The secondary outcomes were maternal complications, neonatal complications, and adverse birth outcomes. The analysis was performed using the DerSimonian-Laird random effects model. RESULTS Eleven studies captured data from 275 parturient with thoracic organ transplant describing 400 pregnancies. The primary outcomes included maternal mortality {pooled incidence (95% confidence interval) 4.2 (2.5-7.1) at 1 year and 19.5 (15.3-24.5) during follow-up}. Pooled estimates yielded 10.1% (5.6-17.5) and 21.8% (10.9-38.8) risk of rejection and graft dysfunction during and after pregnancy, respectively. Although 67% (60.2-73.2) of pregnancies resulted in live birth, total pregnancy loss and neonatal death occurred in 33.5% (26.7-40.9) and 2.8% (1.4-5.6), respectively. Prematurity and low birth weight were reported in 45.1% (38.5-51.9) and 42.7% (32.8-53.2), respectively. CONCLUSIONS Despite pregnancies resulting in nearly 2/3rd of live births, high incidence of pregnancy loss, prematurity and low birth weight remain a cause of concern. Focused pre-conceptual counseling to avoid unplanned pregnancy, especially in women with transplant-related organ dysfunctions and complications, is vital to improve pregnancy outcomes. PROSPERO NUMBER CRD42020164020.
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Affiliation(s)
- Nivedita Jha
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Ajay Kumar Jha
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India.
| | - Sandeep Kumar Mishra
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
| | - Satyen Parida
- Department of Anesthesiology and Critical Care, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India
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Choon XY, Westbrook RH. Pregnancies in recipients of liver transplant. Clin Liver Dis (Hoboken) 2024; 23:e0124. [PMID: 38567096 PMCID: PMC10986916 DOI: 10.1097/cld.0000000000000124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/17/2023] [Indexed: 04/04/2024] Open
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Osman KT, Nayfeh T, Alrukby J, Mehta N, Elkhabiry L, Spencer C, Aby ES. Type of donor liver transplant does not affect pregnancy outcomes-a systematic review and meta-analysis. Liver Transpl 2023; 29:1304-1312. [PMID: 37141916 DOI: 10.1097/lvt.0000000000000168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023]
Abstract
Liver transplant (LT) has become increasingly common among reproductive-aged women. The effect of the type of liver donor, either a living donor LT (LDLT) or a deceased donor LT, on pregnancy outcomes is unknown. As such, we aim to review the available literature and assess obstetric, pregnancy, or delivery outcomes in LDLT. We conducted a comprehensive literature review of MEDLINE, EMBASE, Cochrane, and Scopus databases. Random-effect meta-regression assessed the association between the percentage of women who underwent LDLT (independent variable) and the proportion of outcomes. Meta-regression results were expressed as a regression coefficient, which transforms the proportion of outcomes of interest associated with a 1% increase in the percentage of LDLT patients. A value of 0 denotes no relationship between the outcomes and LDLT. A total of 6 articles (438 patients) were included, with a total of 806 pregnancies. Eighty-eight (20.09%) patients underwent LDLT. None of the studies segregated the data based on the type of donor LT. The median time from LT to pregnancy was 4.86 (4.62-5.03) years. Twelve (1.5%) stillbirths were reported. LDLT was statistically significantly associated with a higher rate of stillbirths (coefficient 0.002, p < 0.001; I 2 0%). The type of donor LT was not associated with an increased risk of other obstetric, pregnancy, or delivery complications. This is the first meta-analysis to evaluate the effect of the type of donor LT on pregnancy outcomes. This study highlights the lack of robust literature addressing this important topic. The results suggest that pregnancy outcomes after LDLT and deceased donor LT are comparable. Despite LDLT being statistically significantly associated with a higher rate of stillbirths, the association is weak and is unlikely to be clinically significant.
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Affiliation(s)
- Karim T Osman
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Tarek Nayfeh
- Evidence-based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Judy Alrukby
- Department of Internal Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Neev Mehta
- Department of Gastroenterology, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Lina Elkhabiry
- Department of Internal Medicine, University of Alexandria, Alexandria, Egypt
| | - Carol Spencer
- Department of Library Services, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Elizabeth S Aby
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
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Coscia L, Cohen D, Dube GK, Hofmann RM, Moritz MJ, Gattis S, Basu A. Outcomes With Belatacept Exposure During Pregnancy in Kidney Transplant Recipients: A Case Series. Transplantation 2023; 107:2047-2054. [PMID: 37287109 PMCID: PMC10442140 DOI: 10.1097/tp.0000000000004634] [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] [Received: 11/01/2022] [Revised: 03/03/2023] [Accepted: 03/10/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Posttransplant fertility returns quickly, and female recipients of child-bearing age may conceive while on immunosuppression. However, pregnancy after transplantation confers risks to the recipient, transplant, and fetus, including gestational hypertension, preeclampsia, gestational diabetes, transplant dysfunction, preterm labor, and low birthweight infants. Additionally, mycophenolic acid (MPA) products are teratogenic. Literature evidence regarding belatacept, a selective T-cell costimulation blocker, during pregnancy and while breastfeeding is extremely limited. When female transplant recipients on a belatacept-based regimen are desirous of pregnancy or at the time of conception, transplant providers manage the immunosuppression regimen in 1 of 2 ways: (1) switch both belatacept and MPA to a calcineurin inhibitor-based regimen with or without azathioprine, which is the more common practice but requires several modifications, having potential negative outcomes; or (2) only switch MPA to azathioprine while continuing belatacept. METHODS This case series includes 16 pregnancies in 12 recipients with exposure to belatacept throughout pregnancy and while breastfeeding. Patient information was obtained from several sources, including Transplant Pregnancy Registry International, providers at Emory University, and Columbia University, as well as literature review. RESULTS Pregnancy outcomes included 13 live births and 3 miscarriages. No birth defects or fetal deaths were reported in any of the live births. Seven infants were breastfed while their mothers continued belatacept. Outcomes appear comparable to those documented with the administration of calcineurin inhibitors. CONCLUSIONS This case series provides data supporting the continued administration of belatacept during pregnancy. Additional research will assist in developing better guidelines to counsel female transplant recipients on belatacept desiring to pursue pregnancy.
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Affiliation(s)
- Lisa Coscia
- Transplant Pregnancy Registry International, Philadelphia, PA
| | - David Cohen
- Department of Medicine, Columbia University, New York, NY
| | | | - R. Michael Hofmann
- Department of Medicine, Trinity Health Kidney Transplant Center, Grand Rapids, MI
| | - Michael J. Moritz
- Transplant Pregnancy Registry International, Philadelphia, PA
- Surgery, Lehigh Valley Health Network, Allentown, PA
- Department of Surgery, Morsani College of Medicine, Tampa, FL
| | - Sara Gattis
- Department of Pharmacy, Emory University School of Medicine, Atlanta, GA
| | - Arpita Basu
- Department of Medicine, Division of Nephrology and Division of Transplant, Emory University School of Medicine, Atlanta, GA
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Kittleson MM, DeFilippis EM, Bhagra CJ, Casale JP, Cauldwell M, Coscia LA, D'Souza R, Gaffney N, Gerovasili V, Ging P, Horsley K, Macera F, Mastrobattista JM, Paraskeva MA, Punnoose LR, Rasmusson KD, Reynaud Q, Ross HJ, Thakrar MV, Walsh MN. Reproductive health after thoracic transplantation: An ISHLT expert consensus statement. J Heart Lung Transplant 2023; 42:e1-e42. [PMID: 36528467 DOI: 10.1016/j.healun.2022.10.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/16/2022] Open
Abstract
Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York
| | - Catriona J Bhagra
- Department of Cardiology, Cambridge University and Royal Papworth NHS Foundation Trusts, Cambridge, UK
| | - Jillian P Casale
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland
| | - Matthew Cauldwell
- Department of Obstetrics, Maternal Medicine Service, St George's Hospital, London, UK
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, Pennsylvania
| | - Rohan D'Souza
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Gaffney
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Patricia Ging
- Department of Pharmacy, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Kristin Horsley
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, Ontario, Canada
| | - Francesca Macera
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Dept of Cardiology, Cliniques Universitaires de Bruxelles - Hôpital Erasme, Brussels, Belgium
| | - Joan M Mastrobattista
- Department of Obstetrics & Gynecology, Division of Maternal-Fetal Medicine, Baylor College of Medicine Houston, Texas
| | - Miranda A Paraskeva
- Lung Transplant Service, Alfred Hospital, Melbourne, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Lynn R Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Quitterie Reynaud
- Cystic Fibrosis Adult Referral Care Centre, Department of Internal Medicine, Hospices civils de Lyon, Pierre Bénite, France
| | - Heather J Ross
- Peter Munk Cardiac Centre of the University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Mitesh V Thakrar
- Department of Medicine, Division of Respirology, University of Calgary, Calgary, Alberta, Canada
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A medication-wide association study (MWAS) on repurposed drugs for COVID-19 with Pre-pandemic prescription medication exposure and pregnancy outcomes. Sci Rep 2022; 12:20314. [PMID: 36433981 PMCID: PMC9700703 DOI: 10.1038/s41598-022-24218-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 11/11/2022] [Indexed: 11/27/2022] Open
Abstract
Information on effects of medication therapies during pregnancy is lacking as pregnant patients are often excluded from clinical trials. This retrospective study explores the potential of using electronic health record (EHR) data to inform safety profiles of repurposed COVID medication therapies on pregnancy outcomes using pre-COVID data. We conducted a medication-wide association study (MWAS) on prescription medication exposures during pregnancy and the risk of cesarean section, preterm birth, and stillbirth, using EHR data between 2010-2017 on deliveries at PennMedicine. Repurposed drugs studied for treatment of COVID-19 were extracted from ClinicalTrials.gov (n = 138). We adjusted for known comorbidities diagnosed within 2 years prior to birth. Using previously developed medication mapping and delivery-identification algorithms, we identified medication exposure in 2,830 of a total 63,334 deliveries; from 138 trials, we found 31 medications prescribed and included in our cohort. We found 21 (68%) of the 31 medications were not positively associated with increased risk of the outcomes examined. With caution, these medications warrant potential for inclusion of pregnant individuals in future studies, while drugs found to be associated with pregnancy outcomes require further investigation. MWAS facilitates hypothesis-driven evaluation of drug safety across all prescription medications, revealing potential drug candidates for further research.
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10
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Neuberger J. Long-term Care of the Adult Liver Transplant Recipient. J Clin Exp Hepatol 2022; 12:1547-1556. [PMID: 36340310 PMCID: PMC9630008 DOI: 10.1016/j.jceh.2022.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/31/2022] [Indexed: 02/05/2023] Open
Abstract
While outcomes after liver transplantation have increased over the last two decades, this is primarily as a consequence of a reduction in early deaths and survival of those who survive the first 6 months has not significantly changed. Causes of premature death and graft loss include cardiovascular disease, renal impairment, malignancy and some infections. As the number of transplant recipients increase, care is being given by primary and secondary care clinicians. Management of the well patient is crucially dependent on careful assessment and where appropriate intervention, especially of cardiovascular risk - such as advice about avoidance of weight gain; management of hypertension, hyperlipidaemia and diabetes; and provision of appropriate lifestyle advice. Other interventions include surveillance for de novo malignancies, active management of immunosuppressive regimen with the need to tailor immunosuppression to the individual. Prompt investigation of abnormalities of liver function is essential. Immune-mediated graft damage still occurs but is less common as a cause for graft loss. Adherence is sometimes an issue, especially in teenagers and young adults, and should be considered and support given where needed. Immunisations (avoiding live and attenuated vaccines) should be encouraged. Recurrence of disease remains an issue, and some interventions (such as appropriate use of antiviral therapy for those grafted with viral hepatitis, use of ursodeoxycholic acid for those grafted for primary biliary cholangitis or long-term steroids for those grafted for autoimmune disease) may improve and maintain graft function. Close collaboration between recipient and the attending clinicians in primary, secondary and tertiary care and close attention to modifiable conditions will lead to improved outcomes.
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Key Words
- CMV, Cytomegalovirus
- CNI, Calcineurin inhibitor
- DRR-4i, dipeptidyl peptidase-4 inhibitor
- GLP 1RA, glucagon-like peptide-1 receptor agonists
- HBIG, Hepatitis B Immunoglobulin
- HBV, Hepatitis B Virus
- HCC, Hepatocellular carcinoma
- HCV, Hepatitis C virus
- LDL-C, Low-density lipoprotein cholesterol
- LT, Liver transplant
- MDRD, Modification of Diet in Renal Disease
- MRC, Magnetic resonance cholangiography
- NAFLD, Non-alcoholic fatty liver disease
- NIDDK, National Institute of Diabetes and Digestive and Kidney Diseases
- NODAT, New onset diabetes after transplant
- NUC, Nucleos(t)ide analogues
- PBC, Primary Biliary Cholangitis
- PSC, Primary Sclerosing Cholangitis
- SGLT2i, sodium–glucose cotransporter 2 inhibitors
- SRTR, Scientific Registry of Transplant Recipients
- TMPT, Thiopurine S-methyltransferase
- USA, United States of America
- cardiovascular disease
- follow-up
- liver transplant
- mRNA, messenger Ribonucleic acid
- mTORi, mammalian Target of rapamycin inhibitor
- malignancy
- recurrent disease
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Affiliation(s)
- James Neuberger
- Liver Unit, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK
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Surgery in Pregnancy. Am J Gastroenterol 2022; 117:53-59. [PMID: 36194034 DOI: 10.14309/ajg.0000000000001961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/23/2022] [Indexed: 12/11/2022]
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Rahim MN, Hedley C, Frick A, Chung Y, Penna L, Long L, Williamson C, Heneghan MA. Development of obstetric-hepatology services: defining optimal care and impact of pregnancy counselling on patient experience. Frontline Gastroenterol 2022; 14:124-131. [PMID: 36818790 PMCID: PMC9933593 DOI: 10.1136/flgastro-2022-102106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/29/2022] [Indexed: 02/24/2023] Open
Abstract
Objective Prepregnancy counselling (PPC) is an important aspect of care for women with chronic liver disease (CLD) and liver transplantation (LT), yet its impact has not been well described. This study aims to assess the experience of women attending a joint obstetric-hepatology PPC clinic in a single-centre unit. Design/methods A retrospective questionnaire-based study in a tertiary unit within the UK where patients who attended the PPC clinic between March 2016 and July 2021 were invited to participate by filling in a questionnaire. Descriptive data and free-text content were subsequently analysed. Results 108 women attended the PPC clinic over a 5-year period. Overall, 58/108 (54%) completed the questionnaire. Principal concerns regarding pregnancy included fears around deterioration in health (66%), maternal death (24%), pregnancy loss (66%), medication effects (60%) and disease transmission (36%). 17/58 (14%) patients felt the presence of multiple doctors was intimidating, however, perceptions improved by the end of the consultation.Overall, 44/58 (76%) respondents felt the clinic helped them reach a decision about pursuing pregnancy. Almost all respondents would recommend the clinic to others. There were no major differences in pregnancy outcomes between those that received PPC and those that did not. Conclusion The PPC clinic facilitates a personalised approach to care and is well received by patients with CLD/LT. It is difficult to elucidate whether attendance alone impacts on pregnancy outcomes; registry data may be better placed at addressing this important question.
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Affiliation(s)
| | | | - Alex Frick
- Department of Obstetrics, King’s College Hospital, London, UK
| | - Yooyun Chung
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Leonie Penna
- Department of Obstetrics, King’s College Hospital, London, UK
| | - Lisa Long
- Department of Obstetrics, King’s College Hospital, London, UK
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Merlo I, Cantarutti A, Allotta A, Tavormina EE, Iommi M, Pompili M, Rea F, Agodi A, Locatelli A, Zanini R, Carle F, Addario SP, Scondotto S, Corrao G. Development and Validation of a Novel Pre-Pregnancy Score Predictive of Preterm Birth in Nulliparous Women Using Data from Italian Healthcare Utilization Databases. Healthcare (Basel) 2022; 10:healthcare10081443. [PMID: 36011100 PMCID: PMC9407812 DOI: 10.3390/healthcare10081443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Preterm birth is a major worldwide public health concern, being the leading cause of infant mortality. Understanding of risk factors remains limited, and early identification of women at high risk of preterm birth is an open challenge. Objective: The aim of the study was to develop and validate a novel pre-pregnancy score for preterm delivery in nulliparous women using information from Italian healthcare utilization databases. Study Design: Twenty-six variables independently able to predict preterm delivery were selected, using a LASSO logistic regression, from a large number of features collected in the 4 years prior to conception, related to clinical history and socio-demographic characteristics of 126,839 nulliparous women from Lombardy region who gave birth between 2012 and 2017. A weight proportional to the coefficient estimated by the model was assigned to each of the selected variables, which contributed to the Preterm Birth Score. Discrimination and calibration of the Preterm Birth Score were assessed using an internal validation set (i.e., other 54,359 deliveries from Lombardy) and two external validation sets (i.e., 14,703 and 62,131 deliveries from Marche and Sicily, respectively). Results: The occurrence of preterm delivery increased with increasing the Preterm Birth Score value in all regions in the study. Almost ideal calibration plots were obtained for the internal validation set and Marche, while expected and observed probabilities differed slightly in Sicily for high Preterm Birth Score values. The area under the receiver operating characteristic curve was 60%, 61% and 56% for the internal validation set, Marche and Sicily, respectively. Conclusions: Despite the limited discriminatory power, the Preterm Birth Score is able to stratify women according to their risk of preterm birth, allowing the early identification of mothers who are more likely to have a preterm delivery.
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Affiliation(s)
- Ivan Merlo
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy; (I.M.); (F.R.); (G.C.)
| | - Anna Cantarutti
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy; (I.M.); (F.R.); (G.C.)
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, 20126 Milan, Italy; (F.C.); (S.P.A.); (S.S.)
- Correspondence: ; Tel.: +39-02-6448-5828; Fax: +39-02-6448-5899
| | - Alessandra Allotta
- Department of Health Activities and Epidemiological Observatory, Regional Health Authority, Sicily Region, 90145 Palermo, Italy; (A.A.); (E.E.T.)
| | - Elisa Eleonora Tavormina
- Department of Health Activities and Epidemiological Observatory, Regional Health Authority, Sicily Region, 90145 Palermo, Italy; (A.A.); (E.E.T.)
- National Research Council of Italy, Institute for Biomedical Research and Innovation, 90146 Palermo, Italy
| | - Marica Iommi
- Center of Epidemiology, Biostatistics and Medical Information Technology, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60020 Ancona, Italy;
| | - Marco Pompili
- Regional Epidemiological Observatory, Regional Health Agency of Marche, 60125 Ancona, Italy;
| | - Federico Rea
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy; (I.M.); (F.R.); (G.C.)
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, 20126 Milan, Italy; (F.C.); (S.P.A.); (S.S.)
| | - Antonella Agodi
- Department of Medical and Surgical Sciences and Advanced Technologies “GF Ingrassia”, University of Catania, 95123 Catania, Italy;
| | - Anna Locatelli
- Department of Mother and Child, ASST Vimercate, 20871 Vimercate, Italy;
- School of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy
| | - Rinaldo Zanini
- Past Director of Woman and Child Health Department, Azienda Ospedaliera della Provincia di Lecco, 23900 Lecco, Italy;
| | - Flavia Carle
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, 20126 Milan, Italy; (F.C.); (S.P.A.); (S.S.)
- Center of Epidemiology, Biostatistics and Medical Information Technology, Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60020 Ancona, Italy;
| | - Sebastiano Pollina Addario
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, 20126 Milan, Italy; (F.C.); (S.P.A.); (S.S.)
- Department of Health Activities and Epidemiological Observatory, Regional Health Authority, Sicily Region, 90145 Palermo, Italy; (A.A.); (E.E.T.)
| | - Salvatore Scondotto
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, 20126 Milan, Italy; (F.C.); (S.P.A.); (S.S.)
- Department of Health Activities and Epidemiological Observatory, Regional Health Authority, Sicily Region, 90145 Palermo, Italy; (A.A.); (E.E.T.)
| | - Giovanni Corrao
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, 20126 Milan, Italy; (I.M.); (F.R.); (G.C.)
- National Centre for Healthcare Research and Pharmacoepidemiology, University of Milano-Bicocca, 20126 Milan, Italy; (F.C.); (S.P.A.); (S.S.)
- Directorate General for Health, Lombardy Region, 20124 Milan, Italy
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Dokmak A, Trivedi HD, Bonder A, Wolf J. Pregnancy in Chronic Liver Disease: Before and After Transplantation. Ann Hepatol 2021; 26:100557. [PMID: 34656772 DOI: 10.1016/j.aohep.2021.100557] [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: 04/17/2021] [Revised: 05/27/2021] [Accepted: 05/27/2021] [Indexed: 02/04/2023]
Abstract
Chronic liver disease poses various challenges for women of reproductive age. Cirrhosis, particularly if decompensated, and liver transplantation may impact gestation and perinatal outcomes. Tailored management of underlying liver disease is critical to optimize maternal and fetal wellbeing. Early education, timely intervention, close monitoring, and a multidisciplinary approach are key elements required to minimize complications and increase chances of a safe and successful pregnancy. In this review, we focus on the pregnancy-related implications of chronic liver disease and liver transplantation on women of reproductive age and highlight disease-specific management considerations.
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Affiliation(s)
- Amr Dokmak
- Department of Hospital Medicine, Catholic Medical Center, Manchester, NH, USA.
| | - Hirsh D Trivedi
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alan Bonder
- Liver Center, Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jacqueline Wolf
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Marzec I, Słowakiewicz A, Gozdowska J, Tronina O, Pacholczyk M, Lisik W, Fleming A, Durlik M. Pregnancy after liver transplant: maternal and perinatal outcomes. BMC Pregnancy Childbirth 2021; 21:627. [PMID: 34530745 PMCID: PMC8447754 DOI: 10.1186/s12884-021-04104-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 08/29/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Liver transplantation is a life-saving and successful therapeutic procedure which is more and more frequent worldwide, also among women of reproductive age. Consequently, there is an increasing number of reports of pregnancy following liver transplantation, but doubts still exist regarding preconception counseling and the optimal method of managing pregnancy. The aim of this study was to report and evaluate pregnancy outcomes in women who had undergone liver transplantation. METHODS We retrospectively analyzed female patients after orthotopic liver transplantation who reported pregnancy and were under medical care of a single transplant center. RESULTS We identified 14 pregnancies in 10 women who had undergone liver transplantation (12 childbirths, one induced abortion due to fetal death in the first trimester, one pregnancy is still ongoing). Causes of transplantation include congenital or acquired disorders and the most common indication was autoimmune hepatitis (50%). The mean age at the point of transplantation was 28.5 (range 21-36), mean maternal age at pregnancy was 32 (range 26-43), and transplant-to-pregnancy interval was 4.07 years (range 1.5-7). The mean gestational week was 36.67 (range 31-40). Immunosuppression was maintained with combinations of prednisone (n = 11), tacrolimus (n = 13), and azathioprine (n = 8) prior to and during pregnancy. Two pregnancies were unintended, so women took mycophenolate mofetil in the first weeks of gestation. Another two women stopped taking azathioprine due to increasing anemia. Maternal complications included increase of aspartate transaminase and alanine transaminase (n = 2), anemia (n = 4) and hyperthyroidism (n = 2). Among the 12 childbirths, five (41.67%) were preterm. Only five women entered labor spontaneously, while seven (58,33%) had cesarean delivery. CONCLUSIONS Pregnancy after liver transplantation can achieve relatively favorable outcomes. Liver transplantation does not influence women's fertility and, during pregnancy, we report low rates of minor graft complications. A multidisciplinary team should be involved in contraceptive, fertility and consequently pregnancy counseling of female transplant recipients.
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Affiliation(s)
- Izabela Marzec
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Nowogrodzka 59, 02-006, Warsaw, Poland
| | - Aleksandra Słowakiewicz
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Nowogrodzka 59, 02-006, Warsaw, Poland
| | - Jolanta Gozdowska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Nowogrodzka 59, 02-006, Warsaw, Poland.
| | - Olga Tronina
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Nowogrodzka 59, 02-006, Warsaw, Poland
| | - Marek Pacholczyk
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Lisik
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Agata Fleming
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Nowogrodzka 59, 02-006, Warsaw, Poland
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Pregnancy Outcomes After Liver Transplantation: A Systematic Review and Meta-Analysis. Am J Gastroenterol 2021; 116:491-504. [PMID: 33657039 DOI: 10.14309/ajg.0000000000001105] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 11/13/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Liver transplantation (LT) remains the gold standard for treatment of end-stage liver disease. Given the increasing number of liver transplantation in females of reproductive age, our aim was to conduct a systematic review and meta-analysis evaluating pregnancy outcomes after LT. METHODS MEDLINE, Embase, and Scopus databases were searched for relevant studies. Study selection, quality assessment, and data extraction were conducted independently by 2 reviewers. Estimates of pregnancy-related outcomes in LT recipients were generated and pooled across studies using the random-effects model. RESULTS A comprehensive search identified 1,430 potential studies. Thirty-eight studies with 1,131 pregnancies among 838 LT recipients were included in the analysis. Mean maternal age at pregnancy was 27.8 years, with a mean interval from LT to pregnancy of 59.7 months. The live birth rate was 80.4%, with a mean gestational age of 36.5 weeks. The rate of miscarriages (16.7%) was similar to the general population (10%-20%). The rates of preterm birth, preeclampsia, and cesarean delivery (32.1%, 12.5%, and 42.2%, respectively) among LT recipients were all higher than the rates for the general US population (9.9%, 4%, and 32%, respectively). Most analyses were associated with substantial heterogeneity. DISCUSSION Pregnancy outcomes after LT are favorable, but the risk of maternal and fetal complications is increased. Large studies along with consistent reporting to national registries are necessary for appropriate patient counseling and to guide clinical management of LT recipients during pregnancy.
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Ziogas IA, Hayat MH, Tsoulfas G. Obstetrical and gynecologic challenges in the liver transplant patient. World J Transplant 2020; 10:320-329. [PMID: 33312893 PMCID: PMC7708880 DOI: 10.5500/wjt.v10.i11.320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 02/06/2023] Open
Abstract
An increasing number of childbearing agewomen undergo liver transplantation (LT) in the United States. Transplantation in this patient subgroup poses a significant challenge regarding the plans for future fertility, particularly in terms of immunosuppression and optimal timing of conception. Intrapartum LT is only rarely performed as the outcome is commonly dismal for the mother or more commonly the fetus. On the other hand, the outcomes of pregnancy in LT recipients are favorable, and children born to LT recipients are relatively healthy. Counseling on pregnancy should start before LT and continue after LT up until pregnancy, while all pregnant LT recipients must be managed by amultidisciplinary team, including both an obstetrician and a transplant hepatologist. Additionally, an interval of at least 1-2 years after successful LT is recommended before considering pregnancy. Pregnancy-induced hypertension, pre-eclampsia, and gestational diabetes mellitus are reported more commonly during the pregnancies of LT recipients than in the pregnancies of non-transplant patients. As adverse fetal outcomes, such asmiscarriage, abortion, stillbirth, or ectopic pregnancy, may occur more often than in the non-transplant population, early planning or delivery either through a planned induction of labor or cesarean section is critical to minimize the risk of complications. No significant long-term physical or phycological abnormalities have been reported in children born to LT recipients.
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Affiliation(s)
- Ioannis A Ziogas
- Medical School, Aristotle University of Thessaloniki, Thessaloniki 54124, Greece
| | - Muhammad H Hayat
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Georgios Tsoulfas
- Department of Surgery, Papageorgiou University Hospital, Aristotle University of Thessaloniki, Thessaloniki 54622, Greece
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