Pregnancy outcome in renal transplant recipients

Ovarian reserve in an Egyptian cohort with end-stage kidney disease on hemodialysis and after successful kidney transplantation: a prospective study

BACKGROUND

Women with chronic kidney disease commonly have menstrual irregularities and fertility abnormalities. Antimüllerian hormone (AMH) and antral follicle count (AFC) are well-recognized indicators of ovarian reserve.

AIMS

To assess AMH level and total AFC in women who are on hemodialysis and after successful kidney transplantation (KTx).

METHODS

Sixty women with end-stage kidney disease (ESKD) on regular hemodialysis were included in this study with 20 patients of them were going to have renal transplant. Fifty age-matched healthy females were enrolled as control. Serum AMH level was measured in all participants once and in transplant patients four times (before surgery, and at 1, 6, and 12 months after surgery). AFC was evaluated once in all subjects and in transplant patients twice (before and 1 year after surgery).

RESULTS

ESKD patients had significantly lower AMH concentration and AFC than healthy controls (1.8 ± 1.2 vs. 3.5 ± 1.7 ng/ml, p < 0.001) and (12 ± 4.6 vs. 17.4 ± 4.3, p < 0.001), respectively. In the subgroup transplant patients, AMH level decreased significantly from (1.7 ± 1.3 ng/ml) before Ktx to (1.5 ± 1.2 ng/ml, p = 0.001) at 1 month, (1.1 ± 0.9 ng/ml, p < 0.001) at 6 months, (0.9 ± 0.8 ng/ml, p < 0.001) at 1 year after Ktx. Also, total AFC declined in transplant females from (11.1 ± 4.5) before KTx to (6.6 ± 3.4) after KTx (p < 0.001).

CONCLUSIONS

Women with ESKD who are on hemodialysis have lower ovarian reserve than healthy females. Moreover, renal transplantation was associated with reduction in AMH level and AFC.

Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review

BACKGROUND

Reproductive function in women with end stage renal disease generally improves after kidney transplant. However, pregnancy remains challenging due to the risk of adverse clinical outcomes.

METHODS

We searched PubMed/MEDLINE, Elsevier EMBASE, Scopus, BIOSIS Previews, ISI Science Citation Index Expanded, and the Cochrane Central Register of Controlled Trials from date of inception through August 2017 for studies reporting pregnancy with kidney transplant.

RESULTS

Of 1343 unique studies, 87 met inclusion criteria, representing 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years. The live-birth rate was 72.9% (95% CI, 70.0-75.6). The rate of other pregnancy outcomes was as follows: induced abortions (12.4%; 95% CI, 10.4-14.7), miscarriages (15.4%; 95% CI, 13.8-17.2), stillbirths (5.1%; 95% CI, 4.0-6.5), ectopic pregnancies (2.4%; 95% CI, 1.5-3.7), preeclampsia (21.5%; 95% CI, 18.5-24.9), gestational diabetes (5.7%; 95% CI, 3.7-8.9), pregnancy induced hypertension (24.1%; 95% CI, 18.1-31.5), cesarean section (62.6, 95% CI 57.6-67.3), and preterm delivery was 43.1% (95% CI, 38.7-47.6). Mean gestational age was 34.9 weeks, and mean birth weight was 2470 g. The 2-3-year interval following kidney transplant had higher neonatal mortality, and lower rates of live births as compared to > 3 year, and < 2-year interval. The rate of spontaneous abortion was higher in women with mean maternal age < 25 years and > 35 years as compared to women aged 25-34 years.

CONCLUSION

Although the outcome of live births is favorable, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making.

Clinical pregnancy after uterus transplantation

OBJECTIVE

To present the first clinical pregnancy after uterus transplantation.

DESIGN

Case study.

SETTING

Tertiary center.

PATIENT(S)

A 23-year-old Mayer-Rokitansky-Kuster-Hauser syndrome patient with previous vaginal reconstruction and uterus transplantation.

INTERVENTION(S)

Eighteen months after the transplant, the endometrium was prepared for transfer of the thawed embryos.

MAIN OUTCOME MEASURE(S)

Implantation of embryo in an allografted human uterus.

RESULT(S)

The first ET cycle with one day 3 thawed embryo resulted in a biochemical pregnancy. The second ET cycle resulted in a clinical pregnancy confirmed with transvaginal ultrasound visualization of an intrauterine gestational sac with decidualization.

CONCLUSION(S)

We have presented the first clinical pregnancy in a patient with absolute uterine infertility after uterus allotransplantation. Although the real success is the delivery of a healthy near-term baby, this clinical pregnancy is a great step forward and a proof of concept that the implantation phase works.

Pregnancy after renal transplantation: a review of registry and single-center practices and outcomes

Registries from North America, Australia and Europe are rich sources of clinical data on pregnancy after kidney transplantation. Single-center reports of pregnancy outcomes are limited by small sample sizes but not by the potential reporting bias that can impact registry data. Despite the differences in data pools, the obstetric and graft outcomes reported by single centers and registries have been similar. The majority of pregnancies are successful in renal transplant patients, but the risk of complications like pre-eclampsia, low birth weight and premature birth is high. Pregnancy has no significant impact on graft function or survival when baseline function is normal.

Pregnancy in renal transplantation: Recipient and donor aspects in the Arab world

OBJECTIVE

There are many kidney transplant recipients and living donors of reproductive age, and the prevalence of pregnancies in kidney transplant recipients can reach 55% in the Middle Eastern countries. Living kidney donation is predominant in this region. As the risks and outcomes of pregnancy should be a part of counselling for both recipients and donors, we reviewed available reports on maternal and foetal outcomes in these particular populations.

METHODS

Information was obtained from retrospective analyses of a large database, and from single-centre reports indexed in PubMed on pregnancy in donors and kidney transplant recipients. The keywords used for the search included 'fertility', 'kidney disease', 'pregnancy', 'maternal/foetal outcomes', 'kidney transplant recipient', 'immunosuppression side-effects', 'living donor' and 'Arab countries'.

RESULTS

Pregnancies in kidney transplant recipients are most successful in those with adequate kidney function and controlled comorbidities. Similarly to other regions, pregnant recipients in the Middle East had a higher risk of pre-eclampsia (26%) and gestational diabetes (7%) than in the general population. Caesarean section was quite common, with an incidence rate of 61%, and the incidence of pre-term birth reached 46%.

CONCLUSIONS

Most living donors can have successful pregnancies and should not be routinely discouraged. Women who had pregnancies before and after donation were more likely to have adverse maternal outcomes (gestational diabetes, hypertension, proteinuria, and pre-eclampsia) in the latter, but no adverse foetal outcomes were found after donation. The evaluation before donation should include a gestational history and counselling about the potential risks.

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.

Long-term neurodevelopment of children exposed in utero to ciclosporin after maternal renal transplant

BACKGROUND

Immunosuppressant therapy is essential in the prevention of organ transplant rejection.

OBJECTIVE

To evaluate the long-term neurodevelopmental outcomes of children following in utero ciclosporin (cyclosporine) exposure after maternal renal transplantation.

METHODS

A cohort study with matched controls using a prospectively collected database was conducted to assess neurocognitive and behavioral outcomes using standardized measures. Thirty-nine children exposed in utero to ciclosporin therapy following maternal renal transplantation were assessed (15 single pregnancies, 24 multiple pregnancies) and compared with 38 matched unexposed children. Intelligence, visuomotor abilities, and psychologic adjustment were measured using the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), the Beery Developmental Test of Visual-Motor Integration (VMI-4) and the Wide Range Assessment of Visual Motor Abilities (WRAVMA), and the Child Behavior Checklist (CBCL), respectively. Statistical analysis, including regression, was performed to determine the significant predictors for the main outcome, full-scale IQ (FIQ).

RESULTS

There were no significant differences in FIQ, verbal IQ (VIQ), performance IQ (PIQ) or behavioral outcomes between exposed and unexposed children or between single and multiple delivery groups. Thirty-three percent of exposed children were premature versus 0.5% in unexposed controls (p < 0.01). Prematurity was associated with low birthweight, high rates of perinatal complications, and instrumental deliveries. Relative to full-term children, premature, low birthweight children in the ciclosporin-exposed group had significantly lower FIQ and VIQ scores (101.04 vs 111.31 [p = 0.008] and 102.31 vs 113.08 [p = 0.021], respectively). Maternal IQ and socioeconomic status were positive and significant predictors for children's IQ (p < 0.001 and p = 0.03, respectively). There were no statistically significant differences in exposed children's IQ who were and were not breastfed.

CONCLUSION

In this cohort, there was no association between in utero exposure to ciclosporin and long-term neurocognitive and behavioral development in children after maternal renal transplantation. Maternal IQ and socioeconomic status are positive predictors for children's intelligence. However, maternal renal transplantation and associated co-morbidity is associated with higher rates of premature delivery and consequent poorer neurocognitive and behavioral outcomes. Proper management of maternal morbidity and improved obstetric care may improve the child's profile.

Successful renal transplantation during pregnancy

Little is known about the implications of performing a renal transplant on a patient who is already pregnant. This case study reports a successful outcome of pregnancy, diagnosed coincidentally following renal transplantation at 13 weeks gestation. The recipient was a 23-year-old woman with chronic kidney disease who received a live-related renal transplant from her father. Pregnancy was discovered at routine ultrasound scanning of the renal allograft at 5 days posttransplant and estimated at 13 weeks gestation. She received ciclosporin monotherapy as immunosuppression throughout the pregnancy, and was given valacyclovir as prophylaxis against cytomegalovirus (CMV) infection. Renal function remained stable throughout the pregnancy, which progressed normally, resulting in the vaginal delivery of a healthy, liveborn male infant at 37 weeks gestation. This case study demonstrates that transplantation during pregnancy can have a successful outcome.

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.

Renal function and lipid metabolism in pregnant renal transplant recipients

OBJECTIVE

To estimate renal function and lipid metabolism in pregnant renal transplant recipients.

STUDY DESIGN

The study covered 64 women during the third trimester of pregnancy including 33 renal transplant recipients (the study group) and 31 healthy women (the control group). Serum concentrations of uric acid, urea, creatinine, electrolytes, total protein, albumin, acid-base balance and blood cell count were examined to assess renal function. Moreover, the levels of the following lipid metabolism parameters were estimated: (1) total lipids (TL), (2) total LDL fraction (TLDL), (3) total cholesterol (TCh), (4) free cholesterol (fCh), (5) free/total cholesterol (fCh/TCh) ratio, (6) phospholipids (PhL), (7) total cholesterol/phospholipids (fCh/PhL) ratio, (8) triglycerides (TG), (9) HDL-cholesterol (HDL-Ch), (10) LDL-cholesterol (LDL-Ch) and (11) LDL-Ch/HDL-Ch ratio. 'The effect of immunosuppressants (cyclosporine, prednisone and azathioprine) on serum lipid levels was estimated in the study group. The mean maternal age, gestational age and BMI did not differ in both groups.

RESULTS

Pregnant renal transplant recipients presented mild renal insufficiency during the third trimester resulting in the increase in serum level of uric acid (P<0.001), urea (P<0.001), creatinine (P<0.001), and Cl- (P<0.001). Proteinuria (1.19+/-1.9 g/24 h) leading to hypoproteinemia (P<0.001) and hypoalbuminemia (P<0.05) confirmed renal function impairment in the study group. Additionally, the diagnosis of renal insufficiency was supported by mild acidosis reflected by a drop in pH (P<0.001). standard HCO3- (P<0.001) and base excess (P<0.001). The women with renal grafts presented vital lipid metabolism disturbances illustrated by the elevated levels of: (1) TL by 72% (P<0.001), (2) TLDL by 21% (P<0.001), (3) TCh by 16% (P<0.001), (4) fCh by 34% (P<0.001), (5) fCh/TCh ratio by 21% (P<0.001), (6) PhL by 28% (P<0.001), (7) TG by 53% (P<0.001), (8) LDL-Ch by 13% (P<0.05) and (9) LDL-Ch/HDL-Ch ratio by 23% (P<0.001). No difference in HDL-Ch level between the two groups was found. Hyperlipidemia in pregnant kidney recipients was associated with immunosuppressive treatment and depended on cyclosporine treatment regimen. Treatment with azathioprine and prednisone was associated with elevated serum levels of examined lipids.

CONCLUSION

Serum lipid abnormalities are significantly influenced by the administered dosages of immunosuppressants.

Menstrual characteristics and pregnancy in women after renal transplantation

OBJECTIVES

To evaluate menstrual characteristics and pregnancy complications after renal transplantation in women of childbearing age.

METHODS

A 10-year retrospective case-control study was carried out in Esfahan Teaching Hospitals, Esfahan, Iran. The case group consisted of 50 female kidney transplant recipients of childbearing age and the control group of 100 women who were matched for age (+/-2 years) and parity with the study group. Menstrual characteristics and pregnancy data were collected by questionnaire and analyzed by chi(2) and t-tests.

RESULTS

Menstrual characteristics were improved in the 50 women who had renal transplantation, 18 of them conceived, and 20 pregnancies were evaluated. The mean interval between transplantation and pregnancy was 35.5 months and the birth weight of 44% of the newborns was less than 2500 g. Pregnancy complications included hypertension (65%), premature labor (35%) and decreased GFR (15%) during pregnancy, with a mean gestational age at delivery of 34.8 weeks. The women who conceived during the first 2 years after renal transplantation had more maternal and neonatal complications.

CONCLUSIONS

Pregnancy is possible and can be successful and safe after renal transplantation in recipients with normal kidney function. However, maternal and neonatal complications are common and occur more often in patients who conceive within 2 years of transplantation. Post-transplantation pregnancies are high risk and they should be managed in a tertiary center.