Pregnancy outcomes for kidney transplant recipients

Successful pregnancy outcome in a recipient of simultaneous pancreatic kidney transplantation

There is limited information available regarding post-simultaneous pancreatic kidney transplantation (SPKT) pregnancies. The present case describes a woman in her early 30s with first pregnancy who conceived spontaneously 4 years after SPKT. Her pancreatic and kidney graft function remained stable throughout the pregnancy. Creatinine was 0.6-0.7 mg/dL and Hemoglobin A1C (HbA1C) was 5.1%. There was no pre-eclampsia, gestational diabetes, rejection or infection. There was gestational thrombocytopenia, which was managed conservatively. Tacrolimus levels fell during the antenatal period and subsequently rose post partum. Mycophenolate was discontinued and switched to azathioprine 6 weeks prior. Caesarean section was done at 36 weeks because of oligohydramnios and vaginal warts delivering a healthy, live, full-term baby. Her graft function was stable on follow-up and the baby was doing well. High-risk pregnancies occur in female SPKT recipients. A multidisciplinary team should closely monitor the course of pregnancy events and immunosuppression.

Labor and Delivery Outcomes in Australian Mothers after Kidney Transplantation

Key Points

Background

Factors influencing high cesarean section rates among mothers with a kidney transplant remain unclear.

Methods

Using linked Australia and New Zealand Dialysis and Transplant Registry (1970–2016) and perinatal datasets (1991–2013), we compared deliveries of women with a functioning kidney transplant with those without KRT (non-KRT).

Results

Of 2,946,851 babies (1,627,408 mothers), 211 were born to 137 mothers with a kidney transplant. Overall cesarean section rates were twice more frequent in the transplant cohort (63% versus 26% non-KRT; P < 0.001) across all gestational periods compared with the non-KRT cohort and highest in preterm births (≥37 weeks, 48% versus 25%; P < 0.001, 33–36 weeks, 77% versus 40%; P < 0.001, and <33 weeks, 75% versus 41%; P < 0.001). Cesarean section rates remained higher after adjusting for maternal factors (incidence rate ratio, 1.5; 95% confidence interval, 1.3 to 1.7). In women with a kidney transplant with past pregnancy, 53% with no previous cesarean sections had a cesarean section in the current pregnancy (versus 19% non-KRT; P < 0.001). Mothers with a kidney transplant had less spontaneous labor (30% versus 63%; P < 0.001) and more planned deliveries (induced or elective cesarean sections; 70% versus 36%; P < 0.001) than non-KRT mothers. Nearly half of the women with transplantation (45%) delivered by nonlabor cesarean sections, mostly occurring preterm (<37 weeks, 70% versus ≥37 weeks, 30%; P = 0.002). In the transplant cohort, the main indications for nonlabor cesarean sections were hypertensive disorders of pregnancy and breech presentation (>50% versus 18% non-KRT cohort; P < 0.001) and were linked to gestational age. Nonlabor cesarean sections for fetal distress were higher in women with transplantation (10% versus 4% non-KRT; P = 0.03). In the non-KRT cohort, previous cesarean sections were the main indication for nonlabor cesarean sections (40% versus 24% transplant; P = 0.06). Postpartum hemorrhage (13% versus 7% non-KRT; P = 0.003) and fetal distress (18% versus 10% non-KRT; P = 0.001) were higher among the transplant cohort.

Conclusions

Women with a kidney transplant have higher rates of cesarean section delivery even after accounting for maternal factors, preterm delivery, and past cesarean sections compared with non-KRT cohorts.

Maternal and neonatal outcomes in kidney transplant recipients: a single-center observational study

OBJECTIVE

Pregnancy poses a high risk for adverse maternal and neonatal outcomes in kidney transplant recipients (KTRs), and data on long-term allograft functions compared to the healthy population are still limited. Therefore, we aimed to conduct a comparative analysis of maternal and neonatal outcomes in KTRs.

SUBJECT AND METHODS

In this retrospective single-center study, KTRs who experienced pregnancy after transplantation were evaluated in comparison with an age-matched non-transplanted control group. Maternal outcomes included obstetric complications (preeclampsia, peripartum hemorrhage, duration of maternal hospitalization) and a composite kidney outcome for KTRs defined as progression to graft failure necessitating dialysis or retransplantation or doubling of serum creatinine at the end of follow-up. Neonatal outcomes were gestational age, preterm birth, newborn mortality, admittance to the neonatal intensive care unit (NICU), Apgar scores, and birth weight.

RESULTS

In 53 KTRs, 68 pregnancies occurred. Preeclampsia (p < 0.001) and preterm birth (p = 0.003) were significantly higher in KTRs. The KTR pregnancies had lower mean birth weights (p = 0.001) and longer durations of maternal hospitalization (p = 0.001). Neonatal mortality, NICU admissions, peripartum hemorrhage rates, and Apgar scores were similar between groups. Follow-up for a median of 105 months after the index birth showed higher serum creatinine levels at postpartum visits (p < 0.001) and at the last follow-up (p = 0.001) compared to baseline. Of the KTRs 6 (11.3%) experienced composite kidney outcomes, including 5 patients with graft failure and 1 with a doubling of serum creatinine.

CONCLUSION

The KTRs exhibit comparable neonatal mortality and NICU admission rates but have higher rates of preeclampsia and preterm birth. Importantly, graft functions worsen significantly during postpartum follow-up.

Adverse Pregnancy Outcomes in Solid Organ Transplant Recipients: A Systematic Review and Meta-Analysis

Importance

Transplant recipients experience high rates of adverse pregnancy outcomes; however, contemporary estimates of the association between solid organ transplantation and adverse pregnancy outcomes are lacking.

Objective

To evaluate the association between solid organ transplantation and adverse pregnancy outcomes and to quantify the incidence of allograft rejection and allograft loss during pregnancy.

Data Sources

PubMed/MEDLINE, EMBASE and Scopus databases were searched from January 1, 2000, to June 20, 2024, and reference lists were manually reviewed.

Study Selection

Cohort and case-control studies that reported at least 1 adverse pregnancy outcome in pregnant women with solid organ transplantation vs without solid organ transplant or studies that reported allograft outcomes in pregnant women with solid organ transplantation were included following independent dual review of abstracts and full-text articles.

Data Extraction and Synthesis

Two investigators abstracted data and independently appraised risk of bias using the Newcastle Ottawa Scale. A random-effects model was used to calculate overall pooled estimates using the DerSimonian-Laird estimator. Reporting followed the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline.

Main Outcomes and Measures

Primary pregnancy outcomes were preeclampsia, preterm birth (<37 weeks), and low birth weight (<2500 g). Secondary pregnancy outcomes were live birth rate, gestation, very preterm birth (<32 weeks), very low birth weight (<1500 g), and cesarean delivery. Allograft outcomes were allograft loss and rejection during pregnancy.

Results

Data from 22 studies and 93 565 343 pregnancies (4786 pregnancies in solid organ transplant recipients) were included; 14 studies reported adverse pregnancy outcomes, and 13 studies provided data for allograft outcomes. Pregnancies in organ transplant recipients were associated with significantly increased risk of preeclampsia (adjusted odds ratio [aOR], 5.83 [95% CI, 3.45-9.87]; I2 = 77.4%), preterm birth (aOR, 6.65 [95% CI, 4.09-12.83]; I2 = 81.8%), and low birth weight (aOR, 6.51 [95% CI, 2.85-14.88]; I2 = 90.6%). The incidence of acute allograft rejection was 2.39% (95% CI, 1.20%-3.96%; I2 = 68.5%), and the incidence of allograft loss during pregnancy was 1.55% (95% CI, 0.05%-4.44%; I2 = 69.2%).

Conclusions and Relevance

In this systematic review and meta-analysis, pregnancies in recipients of a solid organ transplant were associated with a 4 to 6 times increased risk of preeclampsia, preterm birth, and low birth weight during pregnancy. There was a low overall risk of graft rejection or loss during pregnancy.

Pregnancy outcomes post-kidney transplantation across 23 years

BACKGROUND

Pregnancy in kidney transplant recipients has become increasingly common. However, pregnancy carries higher risks to these patients compared to the general population.

AIMS

To describe pregnancy outcomes in kidney transplant recipients.

MATERIALS AND METHODS

We conducted a single-centre retrospective cohort study of kidney transplant recipients who delivered after 20 weeks gestation at a quaternary hospital in Victoria, Australia, between 2000 and 2022 inclusive.

RESULTS

The study included 37 pregnancies from 27 patients, accounting for 38 infants. Over half of recorded pregnancies occurred in the past five years (56.8%, n = 21). There were high rates of pre-existing hypertension (75.7%, n = 28). Pregnancy-induced hypertension and pre-eclampsia were common antenatal complications (21.6%, n = 8 and 48.6%, n = 18 respectively). Soluble fms-like tyrosine kinase-1 / placental growth factor ratios were elevated in all patients who developed severe pre-eclampsia (16.2%, n = 6). The median gestational age at birth was 36.4 weeks (range 20-40.4, Q1 32.9, Q3 37.6) and 59.5% (n = 22) of births were preterm. Unplanned caesarean without labour was the most common mode of birth (35.1%, n = 13). The overall caesarean rate was 62.1% (n = 23). Post-partum haemorrhage complicated over half of pregnancies (56.8%, n = 21). Fifty percent (n = 19) of infants were admitted for neonatal care, in particular neonatal intensive care, and had low birthweights under 2500 g. While there was a transient deterioration in kidney function, there was no graft rejection within one year of birth.

CONCLUSIONS

Clinicians should consider the high rates of pre-existing hypertension, preterm birth, and caesarean birth when counselling and managing pregnant kidney transplant recipients.

Maternal and neonatal outcomes for kidney transplant recipients

OBJECTIVE

To report pregnancy outcomes for women with kidney transplantation and investigate whether different intervals after transplantation have different effects on pregnancy outcomes.

METHODS

A single-center retrospective study was performed. Based on intervals after transplantation, pregnant women with kidney transplantation are divided into two groups: intervals <5 years and ≧5 years. The maternal and neonatal outcomes were compared between the two groups.

RESULTS

No maternal and neonatal deaths occurred. The average age of mothers during pregnancy was 32.3 ± 4.1 years and they had a functioning transplant for 4 (interquartile ranges, 3, 6) years. Preeclampsia occurs in sixteen (16.5 %) pregnancies and gestational diabetes (GDM) occurs in twenty (20.6 %). Eighty-eight newborns (90.7 %) had a gestational age of <37 weeks. The average gestational age for live births was 33.8 ± 2.2 weeks and the average birth weight was 2285.6 ± 581.8 g. Neonatal respiratory distress syndrome (NRDS) occurs in fifty-one babies (52.6 %), intraventricular hemorrhage (ICH) occurs in twenty-nine (29.8 %), atrial septal defects (ASD) occurs in thirty-two (32.9 %) and bronchopulmonary dysplasia (BPD) occurs in seven (7.2 %). Further analysis, pregnancy results, including pre-eclampsia, hypertension or GDM, did not differentiate between the two groups (intervals <5 years vs. ≧5 years). Neonatal outcomes, including premature delivery, low birth weight, mode of birth, small for gestational age (SGA), RDS, ICH, ASD, BPD were not distinguishable between the two groups (intervals <5 years vs. ≧5 years). The level of neonatal blood creatinine after birth was linearly related to high maternal creatinine, and can drop to normal levels within a week.

CONCLUSIONS

The incidence of maternal and neonatal complications in pregnancies following kidney transplantation is still high, despite the success of most pregnancies. Various posttransplant intervals had no significant impact on pregnancy outcomes.

Pregnancy outcomes in renal transplant recipients: A systematic review and meta-analysis

BACKGROUND

Kidney transplantation is a superior treatment for end-stage renal disease (ESRD), compared with hemodialysis, offering better quality of life and birth outcomes in women with ESRD and lower fertility rates.

OBJECTIVES

To investigate the pregnancy, maternal, fetal, and graft outcomes following kidney transplantation in women with ESRD and evaluate the improvements in quality of life and associated risks.

DESIGN

A systematic review and meta-analysis performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the Meta-analysis of Observational Studies in Epidemiology guidelines.

DATA SOURCES AND METHODS

A thorough search of multiple databases, including PubMed, Embase, Scopus, ATC abstracts, and Cochrane Central Register of Controlled Trials, was conducted to identify studies that analyzed pregnancy outcomes in kidney transplant patients. The search was conducted from the inception of each database to January 2023.

RESULTS

The study reviewed 109 studies that evaluated 7708 pregnancies in 5107 women who had undergone renal transplantation. Of these, 78.48% resulted in live births, 9.68% had induced abortion, and 68.67% had a cesarean section. Miscarriage occurred in 12.54%, preeclampsia in 20.87%, pregnancy-induced hypertension in 24.30%, gestational diabetes in 5.08%, and preterm delivery in 45.30% of cases. Of the 853 recipients, 123 had graft loss after pregnancy and 8.06% suffered acute rejection.

CONCLUSION

Pregnancy after kidney transplantation is associated with risks for mother and fetus; however, live births are still possible. In addition, there are reduced overall risks of stillbirths, miscarriages, neonatal deaths, and gestational diabetes.

REGISTRATION

PROSPERO (CRD42024541659).

Placental histopathology and correlated clinical outcomes in kidney transplant recipients

Pregnancies after kidney transplantation are high-risk. Whilst previous studies have explored pregnancy outcomes, there are no existing data on the placental histopathology findings of kidney transplant recipients and how these correlate with clinical outcomes. From 1976 to 2020, 62 pregnancies to 37 transplant recipients were identified in a South Australian clinical unit. The medical records were evaluated to identify if placental tissue had been sent for histopathology. The histology was reviewed contemporaneously, blinded to outcomes, following the Amsterdam consensus. The findings were correlated with the clinical data. Placental tissue was referred for histopathological examination in 20 pregnancies to 15 women. A high rate of adverse perinatal outcomes was noted, with fetal growth restriction (FGR; n=6), pre-eclampsia (n=8), worsening renal function with >10% increase in serum creatinine from preconception (n=9), pre-term birth (n=15), and antenatal hypertension (n=12). Maternal vascular malperfusion was seen in 14/20 pregnancies, including in all cases with pre-eclampsia, and was commonly observed with FGR (5/6 cases), decline in kidney function (8/9), antenatal hypertension (7/12) and preterm birth (12/15). In this high-risk population, increased obstetric ultrasound scans with uterine and umbilical Doppler should be considered to monitor and manage maternal uteroplacental vascular perfusion. We recommend all placental tissue from transplant recipients be referred for histopathological examination.

Pregnancy management and outcome after uterus transplantation

Uterus transplantation is a novel approach in women whose uterus is absent or severely abnormal. However, it is still an experimental procedure that poses risks to both mother and baby. To date, 32 live births after uterus transplantation have been reported in peer-reviewed journals, with several maternal, fetal and neonatal complications. The most common complications were preterm delivery, hypertensive disorders and placenta previa. Four patients experienced episodes of transplant rejection during pregnancy. The appropriate management of complicated and non-complicated pregnancies following uterus transplantation is still unresolved. In this review, obstetric outcomes after uterus transplantation and optimal management during pregnancy are discussed in light of the available data. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Successful pregnancies in post-kidney transplant couples: four case reports

Background

The fertility of female kidney transplant recipients is increasing with the progression of transplant management. This article aims to evaluate the clinical prognosis of mothers and newborns for post-kidney transplant couples.

Methods

From January 2019 to April 2022, a total of four couples, all kidney transplant recipients, were successfully prepared for pregnancy after a rigorous preconception evaluation, including three cases of natural conception and one case of in vitro fertilization. Data regarding the mother and newborn, including general clinical condition and laboratory results, were recorded and assessed throughout the pregnancy and up until 12 months after delivery.

Results

The mean conception age of the mothers was 34.8 years (30-38 years), and the mean interval between renal transplantation and pregnancy was 6.6 years (3.7-8.7 years). All deliveries were by cesarean section and took place without incident. There were three premature births (<37 weeks; average 35.1 weeks). In case 1 (in vitro fertilization), pre-eclampsia occurred during maternity, and this was the only case in which the fetal weight was less than 2,500 g (average 2,576.7 g). The mean Apgar score (1 min) was 7.8 (6-9) and reached 9 in all cases at 5 min. The mothers' eGFR rose during mid-gestation, decreased in late pregnancy, and was largely restored along with proteinuria 1 year postpartum. Postnatal evaluation at 6 months showed normal neurological development. In addition, NK cell and IFN-γ levels increased and Treg cell and IL-10 levels decreased along with the onset of pre-eclampsia.

Conclusions

Pregnancies can succeed in couples who are both kidney transplant recipients. However, there might be higher risks of infertility, prematurity, and low birth weight.

Preeclampsia after Kidney Transplantation: Rates and Association with Graft Survival and Function

BACKGROUND

Transplanted women have high rates of preeclampsia. However, determinants of preeclampsia and association with graft survival and function remain uncertain. We aimed to determine rates of preeclampsia and its association with kidney transplant survival and function.

METHODS

This was a retrospective cohort study analyzing postkidney transplantation pregnancies (≥20 weeks gestation) from the Australia and New Zealand Dialysis and Transplant Registry (2000-2021). Graft survival was assessed in three models accounting for repeated pregnancies and episodes of preeclampsia.

RESULTS

Preeclampsia status was captured in 357 of 390 pregnancies and occurred in 133 pregnancies (37%). The percentage of pregnancies reported to have preeclampsia rose from 27% in 2000-2004 to 48% from 2018 to 2021. Reported prior exposure to calcineurin inhibitors was high overall and higher in women who had preeclampsia (97% versus 88%, P = 0.005). Seventy-two (27%) graft failures were identified after a pregnancy, with a median follow-up of 8.08 years. Although women with preeclampsia had higher median preconception serum creatinine concentration (1.24 [interquartile range, 1.00-1.50] versus 1.13 [0.99-1.36] mg/dl; P = 0.02), in all survival models, preeclampsia was not associated with higher death-censored graft failure. In multivariable analysis of maternal factors (age, body mass index, primary kidney disease and transplant-pregnancy interval, preconception serum creatinine concentration, era of birth event, and tacrolimus or cyclosporin exposure), only era and preconception serum creatinine concentration ≥1.24 mg/dl (odds ratio, 2.48; 95% confidence interval [CI], 1.19 to 5.18) were associated with higher preeclampsia risk. Both preconception eGFR <45 ml/min per 1.73 m 2 (adjusted hazard ratio [HR], 5.55; 95% CI, 3.27 to 9.44, P < 0.001) and preconception serum creatinine concentration ≥1.24 mg/dl (adjusted HR, 3.06; 95% CI, 1.77 to 5.27, P < 0.001) were associated with a higher risk of graft failure even after adjusting for maternal characteristics.

CONCLUSIONS

In this large and contemporaneous registry cohort, preeclampsia was not associated with worse graft survival or function. Preconception kidney function was the main determinant of graft survival.

Counselling, Research Gaps, and Ethical Considerations Surrounding Pregnancy in Solid Organ Transplant Recipients

Survival after solid-organ transplantation has improved significantly, and many contemporary transplant recipients are of childbearing potential. There are limited data to guide decision-making surrounding pregnancy after transplantation, variations in clinical practice, and significant knowledge gaps, all of which raise significant ethical issues. Post-transplant pregnancy is associated with an increased risk of maternal and fetal complications. Shared decision-making is a central aspect of patient counselling but is complicated by significant knowledge gaps. Stakeholder interests can be in conflict; exploring these tensions can help patients to evaluate their options and inform their deliberations. We argue that uniform, evidence-based recommendations for pregnancy after solid organ transplantation are needed. Conducting research, including patient-engaged studies, in this area should be priority for the transplant community.

Pregnancy after Kidney Transplantation-Impact of Functional Renal Reserve, Slope of eGFR before Pregnancy, and Intensity of Immunosuppression on Kidney Function and Maternal Health

Women of childbearing age show increased fertility after kidney transplantation. Of concern, preeclampsia, preterm delivery, and allograft dysfunction contribute to maternal and perinatal morbidity and mortality. We performed a retrospective single-center study, including 40 women with post-transplant pregnancies after single or combined pancreas-kidney transplantation between 2003 and 2019. Outcomes of kidney function up to 24 months after the end of pregnancy were compared with a matched-pair cohort of 40 transplanted patients without pregnancies. With a maternal survival rate of 100%, 39 out of 46 pregnancies ended up with a live-born baby. The eGFR slopes to the end of 24 months follow-up showed mean eGFR declines in both groups (-5.4 ± 14.3 mL/min in pregnant versus -7.6 ± 14.1 mL/min in controls). We identified 18 women with adverse pregnancy events, defined as preeclampsia with severe end-organ dysfunction. An impaired hyperfiltration during pregnancy was a significant risk contributor for both adverse pregnancy events (p < 0.05) and deterioration of kidney function (p < 0.01). In addition, a declining renal allograft function in the year before pregnancy was a negative predictor of worsening allograft function after 24 months of follow-up. No increased frequency of de novo donor-specific antibodies after delivery could be detected. Overall, pregnancies in women after kidney transplantation showed good allograft and maternal outcomes.

Pregnancy in kidney transplantation women: perinatal outcomes and impact on kidney function

OBJECTIVES

This study aimed to evaluate maternal and perinatal outcomes in pregnancies after kidney transplant (KT) and the impact of pregnancy on graft function.

METHODS

A descriptive and retrospective case-control study included 43 pregnancies in women after KT, followed in our institution, from January 1991 to December 2019. The control group included 200 non-transplanted pregnant women. Statistical analysis used SPSS 25.0 (SPSS Inc., Chicago, IL), and a p value of .05 was considered statistically significant.

RESULTS

We studied 43 pregnancies in 37 KT women. The live birth rate of KT pregnant was 81.4%. The mean interval between transplantation and pregnancy was 4.6 years (range 1-16). We found a higher rate of obstetric complications in pregnancies after KT: miscarriage (14.0%, OR 6.7 (2.0-22.1), p < .001), preeclampsia (31.4%, OR 25.7 (7.7-85.3), p < .001), and fetal growth restriction (37.1%, OR 37.6 (9.9-142.3), p < .001). The rate of urogenital infections and anemia during pregnancy was higher in the KT group (p < .001). The gestational age at delivery was 35.0 ± 2.8 weeks and premature delivery was observed in 24 (68.6%) cases. The cesarean rate was higher in the KT group (p < .001). In the KT group, there were two neonatal deaths due to prematurity complications. Renal function deterioration, measured by serum creatinine levels, was observed in two pregnancies. Immunosuppressive therapy was used in all pregnancies after KT, and dosage escalation of immunosuppressive therapy was necessary for 69.8%.

CONCLUSIONS

A higher rate of adverse obstetric outcomes was found in KT pregnant. Kidney function remained stable in most pregnancies. An antenatal and postpartum multidisciplinary approach is essential to improve outcomes and minimization of complications.

A nationwide Dutch cohort study shows relatively good pregnancy outcomes after kidney transplantation and finds risk factors for adverse outcomes

Although numbers of pregnancy after kidney transplantation (KT) are rising, high risks of adverse pregnancy outcomes (APO) remain. Though important for pre-conception counselling and pregnancy monitoring, analyses of pregnancy outcomes after KT per pre-pregnancy estimated glomerular filtration rate-chronic kidney disease (eGFR-CKD)-categories have not been performed on a large scale before. To do this, we conducted a Dutch nationwide cohort study of consecutive singleton pregnancies over 20 weeks of gestation after KT. Outcomes were analyzed per pre-pregnancy eGFR-CKD category and a composite APO (cAPO) was established including birth weight under 2500 gram, preterm birth under 37 weeks, third trimester severe hypertension (systolic blood pressure over 160 and/or diastolic blood pressure over 110 mm Hg) and/or over 15% increase in serum creatinine during pregnancy. Risk factors for cAPO were analyzed in a multilevel model after multiple imputation of missing predictor values. In total, 288 pregnancies in 192 women were included. Total live birth was 93%, mean gestational age 35.6 weeks and mean birth weight 2383 gram. Independent risk factors for cAPO were pre-pregnancy eGFR, midterm percentage serum creatinine dip and midterm mean arterial pressure dip; odds ratio 0.98 (95% confidence interval 0.96-0.99), 0.95 (0.93-0.98) and 0.94 (0.90-0.98), respectively. The cAPO was a risk indicator for graft loss (hazard ratio 2.55, 1.09-5.96) but no significant risk factor on its own when considering pre-pregnancy eGFR (2.18, 0.92-5.13). This was the largest and most comprehensive study of pregnancy outcomes after KT, including pregnancies in women with poor kidney function, to facilitate individualized pre-pregnancy counselling based on pre-pregnancy graft function. Overall obstetric outcomes are good. The risk of adverse outcomes is mainly dependent on pre-pregnancy graft function and hemodynamic adaptation to pregnancy.

Second pregnancy following kidney transplantation is not associated with an increased risk of graft loss in a single center retrospective cohort study

INTRODUCTION

Previous studies on first pregnancy following kidney transplantation (KT) show no association with decreased graft survival. This study examined patients with multiple gestations compared to a single pregnancy following KT and evaluated the risk of graft function deterioration.

METHODS

A retrospective cohort study on fertile female kidney transplant recipients (KTRs) from Rabin Medical Center between January 2001 and December 2017 was performed. Data were collected on patients' comorbidities, pregnancy complications, graft loss, mortality, and lab results. Time-varying COX analysis was performed - second pregnancy being the time-related variable.

RESULTS

Fifty-two KTRs split into 30 single pregnancy and 22 multiple pregnancy patients following KT. Single pregnancy patients were older during their first pregnancy and had a higher caesarian section rate. During a median follow-up period of 5.6 years, multiple pregnancies, compared to a single pregnancy, were not associated with an increased rate of graft loss. No significant difference was seen between first and second pregnancy in gestational age, birth weight, graft function, and proteinuria rates.

CONCLUSIONS

Second pregnancy following KT was not shown to be associated with a decreased graft survival. In addition, obstetrical, maternal, and fetal complication rates are not increased in second compared to first pregnancy following KT.

Parenthood with kidney failure: Answering questions patients ask about pregnancy

Achieving parenthood can be an important priority for women and men with kidney failure. In recent decades, the paradigm has shifted toward greater support of parenthood, with advances in our understanding of risks related to pregnancy and improvements in obstetrical and perinatal care. This review, codesigned by people with personal experience of kidney disease, provides guidance for nephrologists on how to answer the questions most asked by patients when planning for parenthood. We focus on important issues that arise in preconception counseling for women receiving dialysis and postkidney transplant. We summarize recent studies reflecting pregnancy outcomes in the modern era of nephrology, obstetrical, and perinatal care in developed countries. We present visual aids to help clinicians and women navigate pregnancy planning and risk assessment. Key principles of pregnancy management are outlined. Finally, we explore outcomes of fatherhood in males with kidney failure.

Determinants of perinatal outcomes in dialysed and transplanted women in Australia

Introduction

Drivers of adverse perinatal outcomes in pregnancies of women receiving chronic kidney replacement therapy (KRT) remain poorly understood.

Methods

Births ≥ 20 weeks of gestation in Australian women receiving KRT were analyzed for perinatal outcomes stratified by maternal KRT exposure (dialysis or transplant, analyzed separately), by linking the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and perinatal data sets (1991–2013).

Results

Of 2,948,084 babies (1,628,181 mothers), 248 were born to mothers receiving KRT (transplant, n = 211; dialysis, n = 37), with live birth rates ≥ 94%. The perinatal death rate was 162, 62, and 9 per 1000 births in the dialysis, transplant, and non-KRT cohorts, respectively. Babies exposed to KRT had increased odds of prematurity, small-for-gestational age (SGA), poor birth condition, resuscitation, intensive care admission, and longer hospitalization, with the dialysis cohort having worse outcomes. Preterm babies of dialyzed and transplanted mothers (compared with preterm babies with no KRT exposure) experienced 1.6- to 2.7-fold higher odds for all adverse outcomes, except birthweight < 2500 g, which was 11-fold higher for the dialysis cohort. In adjusted analyses, transplanted women with better allograft function (serum creatinine ≤ 120 μmol/l) still had >10-fold higher odds of preterm birth and low birthweight and 1.8- to 4.6-fold increased odds of other adverse outcomes. In transplanted women, mediation analysis revealed that pregnancy-induced hypertension contributed only a modest proportional effect (2.5%–11.2%) on adverse outcomes.

Conclusion

Maternal dialysis and transplantation conferred excess perinatal morbidity, particularly for preterm babies, and even in women with good preconception allograft function. Pregnancy-induced hypertension is not the predominant determinant of perinatal morbidity. Preconception counseling of women with kidney disease should encompass discussion of perinatal complications.

Graft function and pregnancy outcomes after kidney transplantation

Background

After kidney transplantation, pregnancy and graft function may have a reciprocal interaction. We evaluated the influence of graft function on the course of pregnancy and vice versa.

Methods

We performed a retrospective observational study of 92 pregnancies beyond the first trimester in 67 women after renal transplantation from 1972 to 2019. Pre-pregnancy eGFR was correlated with outcome parameters; graft function was evaluated by Kaplan Meier analysis. The course of graft function in 28 women who became pregnant after kidney transplantation with an eGFR of < 50 mL/min/1.73m² was compared to a control group of 79 non-pregnant women after kidney transplantation during a comparable time period and with a matched basal graft function.

Results

Live births were 90.5% (fetal death n = 9). Maternal complications of pregnancy were preeclampsia 24% (graft loss 1, fetal death 3), graft rejection 5.4% (graft loss 1), hemolytic uremic syndrome 2% (graft loss 1, fetal death 1), maternal hemorrhage 2% (fetal death 1), urinary obstruction 10%, and cesarian section. (76%). Fetal complications were low gestational age (34.44 ± 5.02 weeks) and low birth weight (2322.26 ± 781.98 g). Mean pre-pregnancy eGFR was 59.39 ± 17.62 mL/min/1.73m² (15% of cases < 40 mL/min/1.73m²). Pre-pregnancy eGFR correlated with gestation week at delivery (R = 0.393, p = 0.01) and with percent eGFR decline during pregnancy (R = 0.243, p = 0.04). Pregnancy-related eGFR decline was inversely correlated with the time from end of pregnancy to chronic graft failure or maternal death (R = -0.47, p = 0.001). Kaplan Meier curves comparing women with pre-pregnancy eGFR of ≥ 50 to < 50 mL/min showed a significantly longer post-pregnancy graft survival in the higher eGFR group (p = 0.04). Women after kidney transplantation who became pregnant with a low eGFR of > 25 to < 50 mL/min/1.73m² had a marked decline of renal function compared to a matched non-pregnant control group (eGFR decline in percent of basal eGFR 19.34 ± 22.10%, n = 28, versus 2.61 ± 10.95%, n = 79, p < 0.0001).

Conclusions

After renal transplantation, pre-pregnancy graft function has a key role for pregnancy outcomes and graft function. In women with a low pre-pregnancy eGFR, pregnancy per se has a deleterious influence on graft function.

Trial registration

Since this was a retrospective observational case series and written consent of the patients was obtained for publication, according to our ethics’ board the analysis was exempt from IRB approval. Clinical Trial Registration was not done. The study protocol was approved by the Ethics Committee of Hannover Medical School, Chairman Prof. Dr. H. D. Troeger, Hannover, December 12, 2015 (IRB No. 2995–2015).

The experience of being a mother with end stage renal disease: A qualitative study of women receiving treatment at an ambulatory dialysis unit

Background

End-stage kidney disease (ESKD) has considerable effects on the quality of life, impairing daily activities and leading to lifestyle changes. The purpose of this study was therefore to explore the experience of motherhood and taking care of children in women with ESKD.

Methods

A qualitative exploratory study was conducted based on an interpretive framework. Participants were recruited using non-probabilistic purposeful sampling. In total, 14 women with ESKD were included, who were treated at the dialysis unit of a Spanish hospital. In-depth interviews (unstructured and semi-structured interviews) and researchers’ field notes were used to collect the data. A systematic text condensation analysis was performed. The techniques performed and application procedures used to control trustworthiness were credibility, transferability, dependability, and confirmability.

Results

Three themes emerged from the data. “Coping with being a mother” described how women are faced with the decision to become mothers and assess the risks of pregnancy. The second theme, called “Children and the experience of illness”, highlighted the women’s struggle to prevent the disease from affecting their children emotionally or disrupting their lives. The third theme, “Fear of genetic transmission”, was based on the women’s fear of passing the disease on to their children.

Conclusions

Deciding to become a mother and taking care of children represents a challenge for women with ESKD, coupled with the losses in their lives caused by the disease. These findings are only relevant to women on dialysis.

A working partnership: A review of shared decision-making in nephrology

Patients with chronic kidney disease are required to make difficult decisions, negotiating between the risks, burdens and benefits for any proposed course. This process can be extremely challenging, since these decisions involve inherent risks, which can impact on survival and quality of life. Shared decision-making offers a patient-centred approach in partnering with patients to make decisions about their treatment, which reflect their values and preferences. Shared decision-making can improve patient preparedness, motivation, satisfaction, and adherence to the treatment or decision agreed upon. In this review article, we outline the key principles of shared decision-making, and provide a framework with communication strategies to facilitate shared decision-making. We highlight the broad range and context of decisions faced by patients in several areas of nephrology care and discuss patient-important outcomes, priorities and motivations that underpin their decision-making. Preserving patient autonomy through shared decision-making ensures close consideration of patient preferences to enhance satisfaction with the decision reached and optimize outcomes important to patients.

Factors influencing fertility rates in Australian women receiving kidney replacement therapy: Analysis of linked ANZDATA registry and perinatal data over 22 years

BACKGROUND

Pregnancy in women receiving kidney replacement therapy (KRT) is uncommon, and trends and factors influencing fertility rates remain poorly defined.

METHODS

The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) was linked to mandatory perinatal datasets (all births from 1991-2013, ≥20 weeks' gestation) in four Australian jurisdictions. Overall, age and era-specific fertility rates were calculated based on general and KRT population denominators.

RESULTS

From 2,948,084 births, 248 babies were born to 168 mothers receiving KRT (37 babies born to 31 dialysed mothers; 211 babies born to 137 transplanted mothers). Substantial agreement between ANZDATA and perinatal datasets was observed for birth events and outcomes. Transplanted women had higher fertility rates than dialysed women in all analyses, with 21.4 live births/1000 women/year (95% CI: 18.6-24.6) in transplanted women, 5.8 (95% CI: 4.1-8.1) in dialysed women and 61.9 (95% CI: 61.8-62.0) in the Non-KRT cohort. Fertility rates for dialysed women rose in recent years. After adjusting for maternal age and treatment modality, Caucasian women had higher fertility rates, while women with pre-existing diabetes, or transplanted women with exposure to KRT for ≤3.0 years had lower rates. As expected, transplanted women with a pre-conception estimated glomerular filtration rate (eGFR) of < 45 or transplant-to-pregnancy interval of < 1.0 year had lower fertility rates. Geographical location, socioeconomic status and primary disease (glomerulonephritis vs. other) did not affect fertility rates.

CONCLUSIONS

Reporting of births to ANZDATA is sufficiently accurate to justify ongoing data collection. Rising fertility rates in dialysed women may indicate permissive attitudes towards pregnancy. Treatment modality, ethnicity, diabetes, pre-conception eGFR, transplant-to-pregnancy interval and duration of KRT exposure were associated with fertility rates. These factors should be considered when counselling women with kidney disease about parenthood.

Pregnancy outcomes for simultaneous Pancreas-Kidney transplant recipients versus kidney transplant recipients

Data about pregnancy outcomes for simultaneous pancreas-kidney transplant recipients (SPKR) are limited. We compared pregnancy outcomes in SPKR to Kidney Transplant Recipients (KTR) from 2001-17 using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and the Australian and New Zealand Pancreas Islet Transplant Registry (ANZPITR). A total of 19 pregnancies to 15 SPKR mothers, and 348 pregnancies to 235 KTR mothers were reported. Maternal ages were similar (SPKR 33.9 ± 3.9 years; KTR 32.1 ± 4.8 years, p = .10); however, SPKR had a shorter transplant to first-pregnancy interval compared to KTR (SPKR 3.3 years, IQR (1.7, 4.1); KTR 5 years, IQR (2.6, 8.7), p = .02). Median difference in creatinine pre- and post-pregnancy was similar between the groups (KTR -3 µmol/L, IQR (-15, 6), SPKR -3 µmol/L, IQR (-11, 3), p = .86). Maternal, fetal and kidney transplant outcomes were similar despite higher rates of pre-existing peripheral vascular and coronary artery diseases in SPKR. Live birth rates (>20 weeks) were comparable (SPKR 93.8% vs. KTR 96.8%, p = .06). KTR with either type 1 or type 2 diabetes mellitus (24 births) had similar outcomes compared to SPKR. In this national cohort, pregnancy outcomes were similar between SPKR and KTR mothers; however, findings should be interpreted with caution due to small sample sizes.

Schwangerschaft nach sequenzieller Leber-Nieren-Transplantation bei Hyperoxalurie Typ I: Was ist daran anders als sonst?

Schwangerschaft nach Nierentransplantation ist immer ein Risiko sowohl für Mutter und Kind als auch für das Nierentransplantat. Wir beschreiben den Fall einer jungen Frau mit primärer Hyperoxalurie Typ 1 und dadurch bedingtem terminalem Nierenversagen durch Nephrokalzinose. Sie hatte als 10-jähriges Kind eine Lebertransplantation durch Fremdspende erhalten zur Behebung des Enzymdefektes in der Leber sowie 2 Monate später eine Nierentransplantation durch Nierenspende der Mutter. Die Immunsuppression erfolgte durch Cyclosporin, Mycophenolatmofetil und Prednisolon. Das Lebertransplantat hatte 3 Abstoßungen, jeweils behandelt mit Steroidboli. Das Nierentransplantat zeigte eine langsame Funktionsverschlechterung über die Jahre, Entwicklung einer Proteinurie von 1 Gramm Protein pro 1 Gramm Kreatinin sowie eine mittelschwere Hypertonie. Trotzdem hatte die Frau einen persistierenden dringenden Kinderwunsch und setzte sich damit durch. Der Artikel beschreibt die speziellen Probleme dieses Falles: (1) das allgemeine Problem, Patienten mit Hyperoxalurie Typ 1 überhaupt zu transplantieren; (2) das spezielle Problem der Schwangerschaft dieser 31-jährigen Frau mit genetisch bedingter Nierenerkrankung und vorangehender Transplantation von 2 soliden Organen vor 18 Jahren; (3) die mit einem immunologisch instabilen Lebertransplantat und einem Nierentransplantat einhergehende langsam progrediente Funktionsverschlechterung und ansteigende Proteinurie. Die generellen Richtlinien für eine Schwangerschaft nach Nierentransplantation werden aufgezeigt im Vergleich zu dem hier beschriebenen Fall einer Schwangerschaft, bei der fast alle Parameter außerhalb der Richtlinien liegen bei persistierend starkem Kinderwunsch dieser Frau.

Chronic Kidney Disease and Pregnancy

Women with chronic kidney disease (CKD) are at high risk for adverse outcomes in pregnancy. In the United States, pregnancy rates in women with risk factors for CKD such as obesity and advanced maternal age are increasing; thus, more pregnancies are likely to be affected by CKD. Strategies that involve coordinated multidisciplinary care to optimize preconception health, perform meticulous antenatal monitoring, and provide continued care in the postpartum "fourth trimester" appear to be most beneficial for both the mother and baby. Discussions surrounding preconception risk stratification should be individualized based on CKD stage/serum creatinine level, degree of hypertension and proteinuria, and comorbid conditions. Preparation for pregnancy should include optimization of comorbidities and medication adjustments to those compatible with pregnancy. Unless contraindicated, all women with CKD should be prescribed low-dose aspirin in pregnancy to reduce risk of preeclampsia. After delivery, women with CKD may benefit from an early postpartum visit (within 7-10 days) for blood pressure check and may require serial monitoring of serum creatinine and proteinuria as appropriate. Breastfeeding is safe and can be recommended for most women with CKD. A contraceptive plan that includes patients' preferences, feasibility, medical eligibility, duration, and effectiveness of the contraceptive method should be implemented.

Pregnancy after Heart Transplantation

As post-transplant survival improves, many heart transplant (HT) recipients are of, or are surviving to, childbearing age. Solid-organ transplant recipients who become pregnant should be managed by a multidisciplinary cardio-obstetrics team, including specialists in maternal and fetal medicine, cardiology and transplant medicine, as well as anesthesia, neonatology, psychology, genetics, and social services. With careful patient selection, pregnancy after HT can been managed safely. The purpose of this comprehensive review was to summarize the current evidence and recommendations surrounding preconception counseling, medical management and surveillance, maternal outcomes, breastfeeding, and remaining gaps in knowledge.

Parenthood and pregnancy in Australians receiving treatment for end-stage kidney disease: protocol of a national study of perinatal and parental outcomes through population record linkage

INTRODUCTION

Achieving parenthood is challenging in individuals receiving renal replacement therapy (RRT; dialysis or kidney transplantation) for end-stage kidney disease. Decision-making regarding parenthood in RRT recipients should be underpinned by robust data, yet there is limited data on parental factors that drive adverse health outcomes. Therefore, we aim to investigate the perinatal risks and outcomes in parents receiving RRT.

METHODS AND ANALYSIS

This is a multijurisdictional probabilistic data linkage study of perinatal, hospital, birth, death and renal registers from 1991 to 2013 from New South Wales, Western Australia, South Australia and the Australian Capital Territory. This study includes all babies born ≥20 weeks' gestation or 400 g birth weight captured through mandated data collection in the perinatal data sets. Through linkage with the Australian and New Zealand Dialysis and Transplant (ANZDATA) registry, babies exposed to RRT (and their parents) will be compared with babies who have not been exposed to RRT (and their parents) to determine obstetric and fetal outcomes, birth rates and fertility rates. One of the novel aspects of this study is the method that will be used to link fathers receiving RRT to the mothers and their babies within the perinatal data sets, using the birth register, enabling the identification of family units. The linked data set will be used to validate the parenthood events directly reported to ANZDATA.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Human Research Ethics Committees (HREC) and Aboriginal HREC in each jurisdiction. Findings of this study will be disseminated at scientific conferences and in peer-reviewed journals in tabular and aggregated forms. De-identified data will be presented and individual patients will not be identified. We will aim to present findings to relevant stakeholders (eg, patients, clinicians and policymakers) to maximise translational impact of research findings.

Anesthesia management in 14 cases of cesarean delivery in renal transplant patients-a single-center retrospective observational study

Background

The aim of this study was to investigate anesthesia management for cesarean delivery in renal transplant patients.

Methods

The details of anesthesia management, patient characteristics, surgical information, and renal and maternal outcomes were retrospectively investigated in 14 post-renal transplant patients who underwent cesarean delivery at a single university hospital between January 1, 2014, and August 31, 2018.

Results

Five patients were managed under general anesthesia, and nine cases were under regional anesthesia. Nine cases were emergency surgeries. The mean (SD) age was 35.5 (4.4) years, pregnancy body weight was 56.8 (10.0) kg, and gestational age was 33.3 (4.1) weeks. Nine cases were preterm deliveries. Five cases showed hypertension prior to pregnancy, and 13 patients showed hypertension before cesarean delivery. The preoperative creatinine level was 1.49 (0.53) mg/dL. The intraoperative maximum systolic/diastolic blood pressure was 170 (20)/102 (15) mmHg, and the intraoperative minimum systolic/diastolic blood pressure was 97 (13)/49 (12) mmHg. A total of six patients had either mean arterial pressure < 65 mmHg or required vasopressors. Serum creatinine remained unchanged after surgery compared with the preoperative level.

Conclusion

Cesarean delivery was often performed in post-renal transplant patients for preterm delivery or as emergency surgery, with a higher ratio of regional anesthesia to general anesthesia. Since both hypertension and hypotension are most likely to occur during cesarean delivery, circulation management can be difficult, and anesthesia should be managed so as to maintain sufficient renal perfusion and ensure postoperative renal function.

Patient and Graft Outcomes Among Filipino Post-kidney Transplant Pregnancies

BACKGROUND

Kidney transplantation (KT) has been shown to improve fertility rates among women post-transplant. However, despite the favorable outcome, the impact of pregnancy on the graft and the graft's effect on the fetus should be considered. In addition, these patients are exposed to anti-rejection medications that could affect the fetus.

OBJECTIVE

To describe the graft and pregnancy outcomes among KT recipients.

METHODOLOGY

Descriptive study of 32 post-KT recipients who were pregnant from January 1, 2001 to December 31, 2016 and were followed up 3 months post-partum. Each pregnancy was considered as an event.

RESULTS

Among the 32 post-KT patients there were 38 pregnancies. Mean age at conception was 34 years, with a mean interval between KT and pregnancy of 4.8 years. Around 84% took cyclosporine-based immunosuppression. The mean pre-natal serum creatinine was 1.15 mg/dL, 5.3% had ≥ 1.5 mg/dL pre-natal creatinine, and the rejection rate was 10.5%. The results of the pregnancies were as follows: 94% resulted in live births, 18.42% of mothers had pre-eclampsia, 3% had eclampsia, 3% ended in abortion, and 3% were stillbirth. Sixty-eight percent of the pregnancies were unplanned, and more complications were observed among these patients.

CONCLUSION

The maternal and fetal outcomes and complications in this study were comparable with other studies. However, most of these complications were observed with unplanned pregnancies. Counselling prior to pregnancy should therefore be emphasized.

Successful management of twin pregnancy in a woman with advanced chronic kidney disease: A case report

RATIONALE

Twin pregnancy in women with chronic kidney disease (CKD) is very rare but poses a great risk to both mother and children. In developing countries like China, advanced CKD twin pregnancies are often terminated. Here, we report a successful case and reviewed related cases, hope to facilitate further study.

PATIENT CONCERNS

A 29-year-old woman with a twin pregnancy showed serum creatinine (Scr) 100 μmol/L (CKD2) at conception. During her 12th week, Scr reached 263 μmol/L (CKD4) with urine protein 3+ and hypertension.

DIAGNOSES

Due to her pregnancy, renal biopsy was not considered. Lab tests showed deterioration of renal function and ultrasound detections showed small kidney size.

INTERVENTIONS

The patient was given basic drug therapy to control her blood pressure and supplemental nutrition without hemodialysis.

OUTCOMES

The patient delivered 2 healthy babies weighting 0.9 and 0.7 kg by cesarean section at the 28th week, but has been under maintenance hemodialysis since then.

LESSONS

Despite low birth weight and preterm delivery, successful twin pregnancies in some patients with CKD could be realized under early multidisciplinary intervention, but this poses great risks for mothers and twins, especially for patients with advanced CKD and those on hemodialysis.

Serious kidney disease in pregnancy: an Australian national cohort study protocol

BACKGROUND

Maternal kidney disease (acute kidney injury (AKI), advanced chronic kidney disease (CKD), dependence on dialysis or a kidney transplant) has a substantial impact on pregnancy, with risks of significant perinatal morbidity. These pregnancies require integrated multidisciplinary care to manage a complex and often challenging clinical situation. The ability to deliver optimal care is currently hindered by a lack of understanding around prevalence, management and outcomes in Australia. This study aims to expand an evidence base to improve clinical care of women with serious kidney impairment in pregnancy.

METHODS/DESIGN

The "Kidney Disease in Pregnancy Study" is a national prospective cohort study of women with stage 3b-5 CKD (including dialysis and transplant) and severe AKI in pregnancy, using the Australasian Maternity Outcomes Surveillance System (AMOSS). AMOSS incorporates Australian maternity units with > 50 births/year (n = 260), capturing approximately 96% of Australian births. We will identify women meeting the inclusion criteria who give birth in Australia between 1st August 2017 and 31st July 2018. Case identification will occur via monthly review of all births in Australian AMOSS sites and prospective notification to AMOSS via renal or obstetric clinics. AMOSS data collectors will capture key clinical data via a web-based data collection tool. The data collected will focus on the prevalence, medical and obstetric clinical care, and maternal and fetal outcomes of these high-risk pregnancies.

DISCUSSION

This study will increase awareness of the issue of serious renal impairment in pregnancy through engagement of 260 maternity units and obstetric and renal healthcare providers across the country. The study results will provide an evidence base for pre-pregnancy counselling and development of models of optimal clinical care, clinical guideline and policy development in Australia. Understanding current practices, gaps in care and areas for intervention will improve the care of women with serious renal impairment, women with high-risk pregnancies, their babies and their families.

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.

Pregnancy in renal transplant patients: Renal function markers and maternal-fetal outcomes

OBJECTIVES

We aimed to evaluate laboratory markers in women who got pregnant after renal transplantation.

STUDY DESIGN

Cross-sectional prospective study.

MAIN OUTCOME MEASURES

Renal function parameters and maternal and fetal data were assessed in renal transplant recipients.

RESULTS

Forty-three women who got pregnant after renal transplantation (mean age, 28.5 years; mean gestational age, 35.6 weeks) were included. Most patients (53.5%) received a renal transplant from a deceased donor. Podocyturia was not significantly correlated with other renal function markers. Mean period from transplantation to pregnancy was approximately 5 years; this period was not associated with obstetric complications or changes in renal markers. A gradual increase was observed in the following parameters during pregnancy and puerperium: serum creatinine levels (P < 0.001), proteinuria (P < 0.001), urinary protein/creatinine ratio (P < 0.001), and albumin/creatinine ratio (P < 0.001). The sensitivity and specificity of protein/creatinine ratio in predicting preeclampsia were high (96.0% and 94.0%, respectively). Elevated serum creatinine levels, urinary albumin/creatinine ratio, and retinol-binding protein levels in the third trimester were associated with prematurity (P < 0.001). Preeclampsia was the main cause of renal function decline at the end of pregnancy (65.0% of cases). Approximately four (9.5%) pregnant women presented with premature rupture of membranes and 18 (42.0%) with a urinary tract infection.

CONCLUSIONS

Proteinuria, urinary protein/creatinine ratio, and retinol-binding protein levels were elevated in patients with preeclampsia. Using these markers to assess renal function during pregnancy may be clinically useful for detecting and monitoring renal injury in renal transplant recipients.

The patient experience of kidney disease and pregnancy

Achieving parenthood is often a priority and goal for women with chronic kidney disease (CKD). It can be challenging due to medical and emotional complexities around pregnancy planning and care, increased risk of adverse maternal and fetal outcomes, fears about medications such as immunosuppressants and fetal harm, and concerns regarding the impact of pregnancy on women's kidney health. Navigating the pathways for shared decision-making regarding parenthood requires an understanding of the patient's experiences, values, priorities, and needs. In this review, we describe the patient perspective of high-risk pregnancies including those complicated by CKD and outline recommendations for counseling that incorporate these perspectives to improve the patient experience.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

Two pregnancies after simultaneous pancreas-kidney transplantation: A case report

Simultaneous kidney-pancreas transplantation can successfully restore fertility in women with type 1 diabetes mellitus and kidney failure. There have been few cases of pregnancy after simultaneous kidney-pancreas transplantation, and a second pregnancy is rare. We report a case of two live births in rapid succession in a simultaneous kidney-pancreas transplantation recipient, complicated by pre-eclampsia but with excellent fetal and graft outcomes. The first pregnancy was achieved with IVF, while the second was achieved naturally. Simultaneous kidney-pancreas transplantation with stable pre-pregnancy graft function enabled this patient to achieve successful pregnancy. However, both pregnancies were complicated by transient renal graft dysfunction and pre-eclampsia precipitating pre-term birth.

Pregnancy in Renal Transplant Recipients and Donors

Women with renal transplants have restoration of fertility with improved kidney function; however, pregnancy rates in renal transplant recipients appear to be lower than the general population, which might be influenced by patient choice. Women with renal transplants need to evaluate potential neonatal outcomes, graft outcomes, and risks to their own health to make informed decisions about conception. Pregnancy should be carefully planned in renal transplant recipients to reduce risk for graft loss, optimize pregnancy outcomes, and ensure immunosuppression regimes are nonteratogenic. Neonatal outcomes remain significantly worse for women with renal transplants than healthy controls, particularly for those with reduced graft function, hence prepregnancy, antenatal, and postpartum care of women with renal transplants should be guided by a multidisciplinary team of nephrologists and specialist obstetricians.

Reproductive health in women following abdominal organ transplant

Fertility is commonly impaired in women with end-stage kidney and liver disease, although most women will have restoration of fertility within 1 year of transplant. Family planning is therefore critical to discuss with reproductive-aged transplant recipients in the early posttransplant period, in order to ensure timely initiation of contraception, and optimal timing for conception. For women seeking pregnancy, the risks to the mother, graft, and baby should be discussed, including evaluation of immunosuppression safety and potential for adjusting medications prior to conception. With an increasing number of transplant patients now breastfeeding, immunosuppression safety in lactation continues to carry great importance.

A Nationwide Study on Outcomes for the Offspring of Renal Transplant Recipients in Taiwan

OBJECTIVE

Hormonal changes, in either men or women experiencing chronic kidney disease, cause decreased libido, erectile dysfunction, dysmenorrhea, and ovarian dysfunction, all of which may contribute to infertility. Patients' endocrinal and sexual function could be rapidly restored after successful renal transplantation (RTx), which may assist in achieving a successful pregnancy. However, fetuses will be exposed to the immunosuppressive agents passed on from the female recipients, which may be another potential factor leading to a poor fetal outcome. This nationwide study examined the perinatal status of offspring from RTx recipients in Taiwan.

METHODS

The National Health Insurance (NHI) program is a mandatory universal health insurance program in Taiwan which provides coverage for 99.6% of its population. Nationwide, births totaled 2,562,253 between 2001 and 2012. Of that total, 97 births were from mothers who had had a RTx prior to delivery. A total of 2,561,973 births from the general population was then determined by combining the NHI database with the National Birth Registry database. Offspring from the RTx recipients and the general population was at a ratio of 1:10 matched by both birth year and birth month, where 77 offspring were from RTx recipients, while 770 served as a control.

RESULTS

The offspring from the RTx group displayed significant statistical differences from the general population regarding low birth weight (< 2500 g) (53.3% vs 9.9%, P < .001), premature delivery (< 37 weeks) (46.8% vs 10.7%, P < .001), and high cesarean section delivery rate (50.7% vs 38.2%, P = .033). Regarding the Apgar score, which was assessed 1 minute and 5 minutes after each birth, fewer than 7 disclosed rates of 21.3% and 6.7% respectively in offspring of the RTx group; the corresponding numbers were 5.1% (P < .001) and 2.3% (P = .028) respectively in the other group.

CONCLUSION

Upon restoration of fertility after RTx, most female recipients wish to have their own child; therefore, we as doctors have the responsibility to provide the necessary information we possess regarding the outcomes of offspring of female surgery recipients of childbearing age. Consequently, as the outcomes may not be satisfactory, we will continue to require more studies on the long-term outcome of offspring from RTx recipients in order to provide a more rational conclusion.

Successful pregnancy in a recipient of an ABO-incompatible renal allograft

Kidney transplantation restores fertility in patients with end-stage renal disease, with many successful pregnancies after kidney transplantation being reported. However, there are little data regarding pregnancy in women transplanted under modern-era desensitisation protocols that utilise rituximab, plasma exchange and intravenous immunoglobulin, including ABO-incompatible transplants. Pregnancies in ABO-incompatible recipients can pose new challenges from an immunological perspective. Here, we report a case of successful pregnancy using in vitro fertilisation, in a renal transplant recipient who underwent desensitisation two years prior, that included use of rituximab and plasma exchange to receive an ABO-incompatible transplant from her husband and subsequent father of the baby. We believe this was the first case of successful pregnancy after ABO-incompatible kidney transplantation in Australia and New Zealand. This case also highlights the difficulties faced in conception following transplantation and demonstrates that in vitro fertilisation utilising ovulation induction can be successfully utilised for conception in this cohort. This recipient also had gestational diabetes, worsening renal function and preterm delivery which are important complications often seen in pregnancies of solid organ transplant recipients.

Pregnancy outcomes and impact of pregnancy on graft function in women after kidney transplantation

BACKGROUND

Kidney transplantation facilitates pregnancy in women with end-stage kidney disease; however, the impact of pregnancy on short and longer-term graft function is uncertain.

METHODS

Obstetric, fetal, and graft outcomes for pregnancies from a large Australian transplant unit (1976-2015) were reviewed.

RESULTS

There were 56 pregnancies in 35 women with mean age at conception 30.4 ± 0.6 years and mean transplant-pregnancy interval 5.5 ± 0.5 years. The live birth rate was 78.9%. Preterm birth (<37 weeks) occurred in 56.5%. Hypertensive disorders affected 76% of women (pre-eclampsia in 30%). Median prepregnancy serum creatinine (SCr) was 100 μmol/L (interquartile range (IQR), 80, 114 μmol/L). One-third had deterioration in graft dysfunction during pregnancy; of these, 63.2% did not return to baseline. At 2 years post-partum, median SCr was 96.4 μmol/L (IQR, 81.5-124.3). Women with prepregnancy SCr > 110 μmol/L had increased risk of pre-eclampsia (OR 4.4; 95% CI 1.2-16.8; P = .03), but not preterm birth (OR 5.4; 95% CI 0.5-53; P = .04) or low birth-weight babies (OR 1.2; 95% CI 0.5-2.9; P = .04). Women with SCr > 140 μmol/L preconception had worst SCr trajectory, including higher rates of graft loss.

CONCLUSIONS

Kidney transplantation pregnancies remain at high risk of obstetric complications, particularly pre-eclampsia. Prepregnancy graft function can be used to predict risk of adverse pregnancy outcomes and deterioration in graft function during and after delivery.

Monitoring of Human Uterus Transplantation With Cervical Biopsies: A Provisional Scoring System for Rejection

Until now, absolute uterine factor infertility has been the major untreatable form of female infertility. Uterus transplantation has recently proven to be the first successful treatment for absolute uterine factor infertility, with demonstration of live births. In this study, live donation uterus transplantation was performed in nine women. In total, 163 cervical biopsies (149 protocol, 14 follow-up) were taken to detect histopathological signs of rejection. Based on experience from animal experiments, we used a three-grade scoring system to evaluate biopsies systematically. Nine episodes of rejection were diagnosed in five patients: grade 1 in six episodes, grade 2 in two episodes, and grade 3 in one episode. Treatment decisions were based on histopathology, and all rejection episodes were reversed after treatment. The biopsies were reviewed retrospectively, and immunohistochemistry was performed to characterize the inflammatory infiltrates. A borderline category was introduced to avoid overtreatment of patients. Based on our review of all biopsies, we put forward a simple grading system for monitoring of rejection and to guide immunosuppressive treatment in uterus transplantation.

Pregnancy outcomes after kidney transplantation-A single-center experience in Taiwan

OBJECTIVE

This study investigated the pregnancy outcomes of women who had undergone kidney transplantations from 1992 to 2013 in a single medical center.

MATERIALS AND METHODS

Records for patients who had undergone kidney transplantations between 1992 and 2013 at National Taiwan University Hospital, Taipei, Taiwan were retrospectively reviewed, and data on obstetric conditions, neonatal outcomes, and maternal and neonatal complications were collected.

RESULTS

Data for a total of 15 pregnancies in 13 women who had undergone kidney transplantation between 1992 and 2013 were included in this study. The live birth rate was 87%. The mean gestational age was 35.4 ± 3.2 weeks, and the mean birth body weight was 2208.8 ± 678.8 g. Forty percent of the neonates were small for their gestational age (< 10(th) percentile); 53.3% of the pregnancies resulted in preterm deliveries (< 37 weeks); and 26.7% of the neonates needed Neonatal Intensive Care Unit admission. The prevalence rates of preeclampsia and gestational diabetes were 23.0% and 13.3%, respectively.

CONCLUSION

The pregnancy outcomes after kidney transplantation were favorable and the mean birth body weight was 2208.8 ± 678.8 g at 35.4 ± 3.2 weeks gestational age. However, the maternal and neonatal complication rates were still high, such as preterm labor, preeclampsia, and small for gestational age.