Pregnancy in renal allograft recipients: prognosis and management

Outcome of pregnancy after renal transplantation

AIM

The aim of our study was to compare the outcome of pregnancy in patients who became pregnant within 24 months of renal transplantation and patients who became pregnant more than 24 months after renal transplantation.

MATERIALS AND METHODS

The sample population of our prospective cohort study comprised of 44 patients who became pregnant following renal transplantation. In all cases, living donors were used for renal transplantation. The patients were allocated into either group A, which included 24 patients who became pregnant more than 24 months after renal transplantation, or group B, which included 20 patients who inadvertently became pregnant within 24 months of renal transplantation. Serum creatinine and 24-hour urinary protein concentration were measured each trimester. The incidences of preeclampsia and gestational diabetes, the timing and mode of delivery, the rate of preterm labor, and the mean fetal birth weight were determined.

RESULTS

The mean gestational ages in groups A and B were 35.8±3 weeks and 34.1±2.5 weeks, respectively. The mean fetal birth weights in groups A and B were 2,480±316 g and 2,284.5±262 g, respectively. These differences were statistically significant. The incidence of preterm labor was 45.8% in group A and 55% in group B. Proteinuria was significantly higher in group B during the third trimester of pregnancy. Preeclampsia occurred in 25% of the cases in group A and 30% of the cases in group B; this difference was not statistically significant. Gestational diabetes occurred in 2 out of 24 cases in group A and 2 out of 20 cases in group B. For group A and group B, normal vaginal delivery occurred in 58.3% and 55% of cases, respectively, and cesarean section was performed in 41.6% and 45% of cases, respectively.

CONCLUSION

A longer interval between renal transplantation and pregnancy is associated with better pregnancy outcome.

Peripartum anesthetic management of renal transplant patients--a multicenter cohort study

As the number and success of renal transplantation has grown, there has been an increase in the number of renal transplant patients giving birth. To date, there has been no data on obstetric anesthesia management of these patients. The purpose of this study was to build an Israeli national database on parturients after renal transplant. A sixteen-year (calendar years 1996-2011) retrospective study was conducted at three major tertiary centers with a combined current birth rate of approximately 25,000 deliveries annually. We found 83 labors in 64 women. Forty-two percent of this population suffered from hypertension while 12.5% had diabetes. Forty-seven percent of women had a vaginal delivery while 53% of women had a cesarean section. The rate of epidural analgesia for labor was 59%, and rate of regional anesthesia during cesarean section was 75%. There were no anesthetic complications in any cases. Standard ASA monitoring was used in all cases except for one woman with severe hypertension who required an arterial line during her cesarean section. Forty-seven percent of newborn were under 37 weeks with average gestational week 36 ± 3 days and birth weight 2.5 ± 0.7 kg. Average Apgar was 8.4 ± 1.3 at one minute and 9.3 ± 0.7 at five minutes. There was one neonatal death in the CS group due to placental abruption. Patients after renal transplant can safely undergo birth and obstetric analgesia.

Considerations in the medical management of pregnancy in transplant recipients

Pregnancy, although rare in the patient with end-stage renal disease, is not uncommon in the transplant recipient. Physicians taking care of transplant recipients must be able to inform patients about the potential risks of pregnancy in this setting. The patient and her partner must know that the risks associated with pregnancy increase with worsening kidney function and hypertension. Current consensus opinion is that pregnancy can be relatively safely undertaken by 1 year after transplant if the patient has had no rejections during the year, allograft function is adequate, there are no infections that could affect the fetus, the patient is not taking teratogenic medications, and immunosuppressive medication dosing is stable. Consideration must be given to immunosuppression during pregnancy both with respect to the specific agents as well as the level of dosing. None of the medications are FDA category A; all are B or higher. Part of planning for pregnancy should include an evaluation of immunosuppression medication and a plan to modify the regimen prior to conception if its use may be risky for the developing fetus. Rejection can occur during a kidney transplant, so maintaining adequate immunosuppression is important. Other issues that need to be managed when caring for a pregnant transplant patient include: potential for infection (urinary tract infections are very common), hypertension, and anemia. The type of delivery, posttransplant contraception, and breast-feeding also need to be addressed.

Effect of pregnancy on long-term kidney function in renal transplant recipients treated with cyclosporine and with azathioprine

In order to investigate the effect of different immunosuppressive regimens and the time interval between transplantation and pregnancy on long-term outcome, we performed a case-control study in pregnant renal allograft recipients. Eighty-one pregnancies of kidney transplanted recipients were identified [cyclosporine (CYA): n = 40; azathioprine (AZA): n = 41]. Controls were matched with respect to important prognostic factors. Posttransplant follow-up was 91.3 +/- 5 months. Graft and patient survival were similar in both groups and there was no apparent effect of immunosuppression. A total of 28 recipients (33%) delivered within 2 years and 6 (8%) subjects within 1 year after transplantation, but these short transplantation-to-pregnancy intervals had no apparent adverse effect on long-term outcome. In contrast to AZA-treated patients, CYA-treated patients experienced an increase in serum creatinine postpartum (1.15 +/- 0.2 mg/dL vs. 1.61 +/- 0.1 mg/dL; p < 0.05). Whole blood CYA levels decreased transiently during pregnancy from 115.9 +/- 8 ng/mL to 80.7 +/- 7 ng/mL leading to a gradual increase in drug dose from 240 +/- 14 mg/day to 324 +/- 21 mg/day (p < 0.05). Following delivery, there was an increase in CYA concentrations to 173 +/- 5.4 ng/mL, requiring rapid dose tapering to baseline of 246 +/- 15 mg/day. Pregnancies in renal recipients do not affect long-term patient and graft survival, independent of the immunosuppression. No detrimental effect of short transplantation-to-pregnancy intervals on long-term graft function was detected.

Unwanted Pregnancy Among Kidney Transplant Recipients in Iran

To investigate the incidence of unwanted pregnancy among kidney transplant recipients, we studied 86 pregnancies in 64 women with a transplanted kidney. Twenty-five pregnancies were unwanted (29.1%). Pregnancy was terminated by induced abortion in seven patients, and four pregnancies were lost due to spontaneous abortion with one intrauterine fetal death. Only 13 (52%) pregnancies resulted in a live birth. Most of the unwanted pregnancies occurred in women using coitus interruptus (92%) as the only method of contraception. It is concluded that because fertility greatly improves after kidney transplantation, it is necessary to have a family planning counseling session before surgery. If a patient is not interested in future pregnancy, an effective method of contraception should be offered. A woman who has decided against childbearing in the future may decide to have a tubal ligation at the time of transplantation surgery.

The safety of 6-mercaptopurine for childbearing patients with inflammatory bowel disease: a retrospective cohort study

BACKGROUND & AIMS

6-mercaptopurine/azathioprine is effective in IBD patients. However, data regarding toxicity associated with pregnancy are lacking, raising both patients' and physicians' concerns and sometimes resulting in elective abortion.

METHODS

To evaluate potential toxicity of 6-mercaptopurine (6-MP), we reviewed the records of 485 patients who had received the drug. We contacted 462, of whom 155 had conceived at least 1 pregnancy after developing IBD. Pregnancies were analyzed as to whether the patient had taken 6-MP before, or at the time of, conception. These were compared with IBD patients who had their pregnancies before taking 6-MP. We collected data on live births, spontaneous abortions, prematurity, abortions secondary to birth defects, major and minor congenital birth defects, infections, and neoplasia. Outcomes were analyzed comparing pregnancies from men and women who had taken or were currently taking 6-MP to controls.

RESULTS

There was no statistical difference in conception failures (defined as a spontaneous abortion), abortion secondary to a birth defect, major congenital malformations, neoplasia, or increased infections among male or female patients taking 6-MP compared with controls (RR = 0.85 [0.47-1.55], P = 0.59).

CONCLUSIONS

6-MP use before or at conception or during pregnancy appears to be safe. Discontinuation of the drug before and during pregnancy is not indicated.

Treating inflammatory bowel disease during pregnancy: risks and safety of drug therapy

The safety of drug therapy for inflammatory bowel disease during pregnancy is an important clinical concern. Current available information is largely derived from animal studies and clinical experience among patients with inflammatory bowel disease and autoimmune disorders and organ transplant recipients. However, these data are confounded by various factors including difficulty projecting the results of animal studies to humans, methodological deficiencies of some studies, insufficient experience with certain agents, difficulty distinguishing the fetal effects of underlying disease from drug therapy and a need to consider the impact of background rates of adverse fetal outcomes which apply to all pregnancies. In inflammatory bowel disease, the effects of active inflammation on the fetus are believed to be more harmful than those of drug treatment, and therapy is often justified to induce or maintain remission during pregnancy. The choice of appropriate treatment is determined by the severity of the disease and the potential for drug toxicity. No causal relationship has been established between exposure to sulfasalazine or other 5-aminosalicylic acid drugs and the development of congenital malformations. These drugs may be used with relative safety during pregnancy and lactation. Considerable experience with corticosteroids have shown them to pose very small risk to the developing fetus. Current evidence indicates that maternal use of azathioprine is not associated with an increased risk of congenital malformations, though impaired fetal immunity, growth retardation or prematurity is occasionally observed. Preliminary evidence derived from patients with inflammatory bowel disease show no significant fetal toxicity following first trimester exposure to mercaptopurine, though its elective use in pregnancy is controversial. Cyclosporin is not teratogenic, but may be associated with growth retardation and prematurity. Pregnancy should be avoided in women treated with methotrexate because of its known abortifacient effects and risk of causing typical malformations. Although treatment with metronidazole or ciprofloxacin for short durations appear to be devoid of adverse fetal reactions, the effect of prolonged exposure as required in Crohn's disease remains unknown.

Specific immune tolerance during pregnancy after renal transplantation

Pregnancy is associated with specific immunological tolerance to fetal antigens suggesting that immunoregulatory processes during pregnancy can induce specific immunological unresponsiveness. We report a case of a female renal transplant recipient who stopped immunosuppressive therapy during first pregnancy. Despite histologically proven acute renal allograft rejection during the early course of transplantation, no immunological response was observed for 9 years after withdrawal of immunosuppression. Two further pregnancies within that time period did not evoke any renal complications, but were complicated by premature rupture of the amnion and by the development of preeclampsia. To our knowledge, there are no reports of such a long-term specific unresponsiveness to a renal allograft without immunosuppressive therapy. Natural and active immunoregulatory mechanism can be related for the development of specific immune tolerance to renal allograft in this case.

Effect of pregnancy on long-term function of renal allografts

Pregnancy in renal allograft recipients is associated with hyperfiltration with the potential for glomerular damage and adverse effects on long-term graft prognosis. We have undertaken a case-controlled study of posttransplant follow-up for a mean of 12 years (range, 4 to 23) in 36 female renal allograft recipients, 18 who became pregnant and 18 controls (matched to underlying disease and renal function) who did not. Assessments included plasma creatinine (PCr), glomerular filtration rate (GFR) by infusion clearance of inulin (Cin), mean arterial pressure (MAP), and documentation of antihypertensive therapy. By the end of follow-up, PCr in the pregnancy group (112 +/- 73 mumol/L [1.26 +/- 0.83 mg/dL]) and controls (127 +/- 52 mumol/L [1.44 +/- 0.59 mg/dL]) had increased by 19% and 8%, respectively, and GFR in the pregnancy group (58 +/- 29 mL/min) and controls (56 +/- 32 mL/min) had decreased by 18% and 7%, respectively. Graft loss or chronic rejection occurred in two patients in each group and there was a death in the pregnancy group 9 years after the second of two successful pregnancies. MAP in the pregnancy group (96 +/- 12 mm Hg) had decreased by 1%, and in the controls (101 +/- 9 mm Hg) had increased by 5%. Two patients in the index group and three in the control group commenced antihypertensive therapy during follow-up. There was, therefore, no evidence of an adverse effect of pregnancy in renal allograft recipients on long-term renal function or development of hypertension.

Pregnancy outcome in renal allograft recipients: influence of ciclosporin A

The outcome of 35 pregnancies in 26 renal allograft recipients is reported. Twenty-four pregnancies in patients treated with prednisolone and azathioprine resulted in 22 live-born infants (one twin pregnancy) and 3 induced abortions on medical indications. Three of the deliveries were preterm, and one of the infants had a birth weight below the 2.5th percentile. Ten patients (11 pregnancies) were treated with ciclosporin A (CsA). These women delivered 5 infants (3 preterm deliveries of whom the birth weight of one infant was below the 5th percentile) and underwent 3 induced (medical indications) and 3 spontaneous abortions. Mean birth weight in the CsA treated group was 2464 g (range 1790-2930 g), and their gestational age varied from 232 to 271 days. No foetal malformations were observed in the two groups. The results may indicate a harmful effect of CsA on pregnancy outcome.

Dialysis, transplantation, and pregnancy

Women on regular dialysis are usually infertile, but contraception should not be neglected. Pregnancy is invariably complicated and poses excessive risks, with an uncertain and low chance of success. Even when therapeutic abortion is excluded, the live birth outcome at best is 19%. Renal transplantation usually reverses abnormal reproductive function and comprehensive pre-pregnancy counseling is essential, with discussion of all implications, including the harsh realities of long-term maternal survival. In this survey of 2,309 pregnancies in 1,594 women, therapeutic abortion was undertaken in 27% of conceptions and the spontaneous abortion rate was 13%. Of the conceptions that continued beyond the first trimester, 92% ended successfully. In most, renal function was augmented in pregnancy, with transient deterioration in late pregnancy (with or without proteinuria). Permanent renal impairment occurred in 15% of pregnancies. There was a 30% chance of developing hypertension, preeclampsia or both. Preterm delivery occurred in 50%, and intrauterine growth retardation in 25% of pregnancies. Despite its pelvic location, the transplanted kidney rarely produced dystocia and was not injured during vaginal delivery. Cesarean section should be reserved for obstetric reasons only. Neonatal complications include respiratory distress syndrome, leukopenia, thrombocytopenia, adrenocortical insufficiency, and infection. No predominant or frequent developmental abnormalities have been described and data on infancy and childhood are encouraging. For the future more work is needed to improve pre-pregnancy assessment criteria, to understand the mechanisms of gestational renal dysfunction and proteinuria, to assess the side effects and implications of immunosuppression in pregnancy, and to elucidate the remote effects of pregnancy on both renal prognosis and the offspring.