Intrauterine hypotrophy and premature births in neonates delivered by female renal and liver transplant recipients

Uterine Artery Pulsatility Index in Pregnant Kidney or Liver Recipients and Its Impact on Perinatal Outcome

BACKGROUND

The uterine artery pulsatility index (UtA PI) is associated with blood flow to the placenta. Its increased values imply impaired placentation. This study aimed to evaluate UtA PI measurements in first-trimester ultrasound in pregnancies after kidney (KTx) or liver transplantation (LTx) and its relationship with perinatal outcome.

MATERIALS AND METHODS

A retrospective analysis of 72 pregnancies in female kidney (35) or liver (37) transplant recipients between 2017 and 2023 was performed. Data concerning UtA PI were available for 17 kidney and 19 liver recipients. Statistical analysis of variables between KTx and LTx groups and the correlation with perinatal outcomes was performed using Student's t test and Pearson's correlation with P < .05 considered statistically significant.

RESULTS

The mean UtA PI results were similar, and there were no statistical differences between the group of pregnant kidney and liver recipients with mean values of 1.46 (SD 0.44] and 1.73 (SD 0.51] respectively (P = .10). The mean neonate birth weight was lower in KTx group (2158 g ([SD 723 g]) compared with the LTx group (2780 g [SD 754g]; P =.02). In the KTx and LTx groups, mean UtA PI was in negative correlation with Apgar score in the first minute (P = .04, P = .01 respectively).

CONCLUSIONS

Uterine artery Doppler is useful in predicting perinatal outcomes in the general population and organ recipient pregnancies, even in the early stages of pregnancy, as we observed the correlation between UtA PI and Apgar score. Pregnant kidney recipients remain at higher risk for complications and more unpredictable outcomes than liver recipients.

Pregnancy Outcomes After Liver Transplantation: A Systematic Review and Meta-Analysis

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.

[Pregnancies after kidney transplant: What are the consequences for the cognitive development of children?]

Thanks to medical progress in the field of kidney transplantation, the quality of life of women suffering from kidney failure has greatly improved in recent years. As a result, their fertility has increased significantly and pregnancies are now more frequent and safer. Kidney transplantation requires constant immunosuppressive treatment during pregnancy. These products can cross the placental barrier and their prescription is therefore subject to rigorous medical monitoring. There are many environmental factors that can affect the development of the child during pregnancy and affect its subsequent cognitive development. The possible impact of these immunosuppressive treatments on the medium- and long-term intellectual development of the children concerned is as yet little documented. Even if the available data are reassuring, the methodologies used in this work nevertheless raise questions and legitimize the development of complementary research. The aim of this review is to propose a synthesis of existing data in this field and to open up avenues for future research.

Selected Biochemical Parameters in Children of Mothers After Kidney Transplantation

INTRODUCTION

The number of pregnant kidney graft recipients receiving immunosuppressive drugs is increasing yearly. All potentially nephrotoxic and hepatotoxic immunosuppressive drugs penetrate through the placenta, which raises questions about their long-term effects on offspring.

OBJECTIVES

The study aimed to evaluate the influence of immunosuppressive drugs used by pregnant women after kidney transplantation on the biochemical parameters of their children.

MATERIALS AND METHODS

Forty children born to mothers after kidney transplantation (KTx) and 40 children of healthy mothers from the control group were included in the study. All graft-recipient mothers received immunosuppressive treatment during pregnancy. The study compared biochemical parameters, including urea, creatinine, potassium, and sodium, in both groups.

RESULTS

Elevated creatinine level was observed in 1 newborn in the KTx group and none of the children from the control group (P = .500). All KTx children had normal urea levels, while in the control group, 2 newborns had an increased level of urea (P = .247). Elevated potassium levels were observed in 10% of children in the KTx group and 20% of children in the control group (χ² = 0.881; P = .348). Elevated sodium levels were observed in 22.5% of children in the KTx group and 32.5% of children in the control group (χ² = 1.001; P =.317). No child in the KTx group had hyponatremia; mild hyponatremia was observed in 5% of children in the control group (P = .247).

CONCLUSION

There was no increased risk of an abnormal concentration of urea, creatinine, sodium, and potassium in the offspring of mothers after kidney transplantation using immunosuppressive drugs during pregnancy.

Otoacoustic Emissions in Rural Nicaragua: Cost Analysis and Implications for Newborn Hearing Screening

Objective (1) Determine the incidence and risk factors for congenital hearing loss. (2) Perform cost analysis of screening programs. Study Design Proportionally distributed cross-sectional survey. Setting Jinotega, Nicaragua. Subjects and Methods Otoacoustic emissions (OAEs) were used to screen 640 infants <6 months of age from neonatal intensive care unit, institutional, and home birth settings. Data on 15 risk factors were analyzed. Cost of 4 implementation strategies was studied: universal screening, screening at the regional health center (RHC), targeted screening, and screening at the RHC plus targeted screening. Cost-effectiveness analysis over 10 years was based on disability-adjusted life year estimates, with the World Health Organization standard of cost-effectiveness ratio (CER) / gross domestic product (GDP) <3, with GDP set at $4884.15. Results Thirty-eight infants failed the initial OAE (5.94%). In terms of births, 325 (50.8%) were in the RHC, 69 (10.8%) in the neonatal intensive care unit, and 29 (4.5%) at home. Family history and birth defect were significant in univariate analysis; birth defect was significant in multivariate analysis. Cost-effectiveness analysis demonstrated that OAE screening is cost-effective without treatment (CER/GDP = 0.06-2.00) and with treatment (CER/GDP = 0.58-2.52). Conclusions Our rate of OAE failures was comparable to those of developed countries and lower than hearing loss rates noted among Nicaraguan schoolchildren, suggesting acquired or progressive etiology in the latter. Birth defects and familial hearing loss correlated with OAE failure. OAE screening of infants is feasible and cost-effective in rural Nicaragua, although highly influenced by estimated hearing loss severity in identified infants and the high travel costs incurred in a targeted screening strategy.

Pregnancy in the liver transplant recipient

During gestation, the woman's body undergoes various changes, and the line between physiology and pathology is very thin even in healthy women. Today, many of the liver transplant recipients are young women, who at one point in their lives may consider the possibility of pregnancy. Clinicians have to counsel them about the time of conception, the risk of miscarriage, the deterioration of the mother's health status, and the risk of birth defects. This review, based on our 20 years of clinical experience and up-to-date literature, provides comprehensive guidelines on pregnancy management in liver transplant recipients. Pregnancy in liver transplant recipients is possible but never physiological. Proper management and pharmacotherapy lowers the incidence of complications and birth defects. Critical factors for perinatal success include stable graft function before pregnancy, proper preparation for pregnancy, and cautious observation during its course. Liver Transplantation 22 1408-1417 2016 AASLD.

Immunophenotypic profile and increased risk of hospital admission for infection in infants born to female kidney transplant recipients

Children born to female kidney recipients are exposed to immunosuppressive drugs during gestation. Little is known about their immune system at birth or in the long term. Twenty-eight children born to female kidney recipients and 40 full-term children born to healthy mothers were evaluated. T, B, NK, NKT, γδT cells were assessed by flow cytometry and functional evaluation of T and dendritic cells after in vitro activation was performed at birth and at 8 months of age. At birth, infants born to female kidney recipients showed lower numbers of CD4+ T, NKT and intense reduction of B cells (median cells/mm(3) , transplant: 153.7 X control: 512.4; p < 0.001). There was also a reduced percentage of activated CD8+ T and of CD4+ regulatory T cells. Activated memory and exhausted memory B cells showed higher percentages among children exposed to immunosuppressors when compared to control group. At 8 months, most immune alterations were no longer observed, but four children still had low numbers of some lymphocyte subsets at this age. Children born to female kidney recipients had 4.351 (95% CI: 1.026-15.225; p = 0.046) higher risk of hospital admission in the first months of life-some, with severe clinical manifestations-than those born to healthy women.

Risk of obstetrical complications in organ transplant recipient pregnancies

Pregnancy after kidney and liver transplantation is becoming relatively common, although, in both groups, maternal complications are higher than in the general population. Both mean gestational age and mean birthweight seems significantly greater for liver transplant versus kidney transplant recipients and the risk of hypertension during pregnancy seems also lower for liver transplant than kidney transplant recipients. Thus, sequelae of chronic kidney diseases have stronger adverse effects on pregnancy, leading to a higher occurrence of adverse neonatal complications. Also, gestation in heart recipients may be complicated and preeclampsia seems to occur more frequently. However, the transplanted heart seems to adapt well to changes caused by pregnancy, such as increased cardiac workload and output, and elevated maternal oxygen consumption. More problematic is pregnancy in lung transplant recipients. Spontaneous pregnancy and healthy childbirth after bone marrow grafting is relatively rare due to irradiation, but, if gestation occurs, no specific problems have been identified. Obstetrical syndromes associated with transplantation reflect the pathology of defective deep placentation, where conversion of uterine spiral arteries remains largely restricted to the decidual segment. The myometrial segments of the uteroplacental arteries have a unique vascular memory and are at great risk to develop obstructive, atherosclerotic lesions. A similar increased risk of complications already existed in pregnancies during the years before transplantation. The effect of immunosuppressive therapy remains speculative. Therefore, the main target for improving the outcome of pregnancy in women at risk is the strict antihypertensive treatment from the earliest stage of pregnancy.

Pregnancy following liver transplantation: review of outcomes and recommendations for management

Liver transplantation is considered to be the treatment of choice for end-stage liver disease and its success has led to an increase in the number of female liver transplant recipients who are of childbearing age. Several key issues that are noted when counselling patients who are considering pregnancy following liver transplantation include the optimal timing of pregnancy, optimal contraception methods and the management of immunosuppression during pregnancy. The present review summarizes the most recent literature so that the clinician may address these issues with their patient and enable them to make informed decisions about pregnancy planning. The authors review recent studies examining maternal and fetal outcomes, and the rates of complications including risk of graft rejection. Subsequently, the authors provide recommendations for counselling prospective mothers and the management of the pregnant liver transplant recipient.