1
|
DeFilippis EM, Donald EM, Hoffman K, Rosario KF, Agarwal R, Shapiro H, Hong KN, Khush KK, Punnoose L, Kittleson MM. Patient Perceptions and Knowledge Surrounding Pregnancy After Heart Transplantation: A Multicenter Study. Circ Heart Fail 2024; 17:e011741. [PMID: 39087365 PMCID: PMC11335446 DOI: 10.1161/circheartfailure.124.011741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/06/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND More women of childbearing age are surviving after heart transplantation (HT), many of whom have a desire to become pregnant. Limited data exist evaluating patients' perspectives, receipt of counseling, and knowledge surrounding contraception, pregnancy, breastfeeding, and medication safety after HT. METHODS We conducted a voluntary, confidential, web-based cross-sectional survey of women who were childbearing age (defined as 18-45 years) at the time of HT. Transplants occurred between January 2005 and January 2020. Surveys were conducted across 6 high-volume HT centers in the United States. RESULTS There were 64 responses from women who were of childbearing age at the time of HT. Twenty-five women (39.1%) were pregnant before HT, and 6 (9.4%) women reported at least 1 pregnancy post-transplant. Fifty-three percent (n=34) reported they did not receive enough information on post-HT pregnancy before listing for HT, and 26% (n=16) did not discuss their ability to become pregnant with their care team before proceeding with HT. Following HT, 44% (n=28) still felt that they had not received enough information regarding pregnancy. The majority of women (n=49, 77%) had discussed contraception to prevent unplanned pregnancy with their transplant team. Twenty percent (n=13) reported that pregnancy was never safe after transplantation based on the information they had received from their transplant providers. CONCLUSIONS Many women feel they are not receiving adequate counseling with regard to posttransplant reproductive health. This survey highlights an opportunity to improve both provider education and patient communication to better support women with HT desiring posttransplant pregnancy.
Collapse
Affiliation(s)
- Ersilia M. DeFilippis
- Center for Advanced Cardiac Care, Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York, USA
| | - Elena M. Donald
- Center for Advanced Cardiac Care, Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center, New York, New York, USA
| | - Karlee Hoffman
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | | | | | - Hilary Shapiro
- Division of Cardiology, University of California San Diego Medical Center, San Diego, CA
| | - Kimberly N. Hong
- Division of Cardiology, University of California San Diego Medical Center, San Diego, CA
| | - Kiran K. Khush
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Lynn Punnoose
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| |
Collapse
|
2
|
Coscia LA, Kliniewski D, Constantinescu S, Moritz MJ. Pregnancy after transplant in the older adolescent: Anticipatory guidance for the pediatric provider. Pediatr Transplant 2024; 28:e14752. [PMID: 38682682 DOI: 10.1111/petr.14752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Healthcare providers who care for adolescent and young adult transplant recipients should be aware of contraception counseling and potential for pregnancy in this at-risk cohort. METHODS This paper will review contraceptive options in general for transplant recipients. There will also be a review of common immunosuppressive medications and their risk profile regarding pregnancy after transplantation. Data from the Transplant Pregnancy Registry International were analyzed looking at recipients conceiving under the age of 21 and were compared to overall pregnancy outcomes. RESULTS Overall pregnancy outcomes in recipients under the age of 21 are like the adult cohort. CONCLUSION It is imperative to provide contraception counseling to the adolescent and young adult and inform their caregiver that pregnancy can happen if the recipient is sexually active. Pregnant adolescent and young adult transplant recipients should be followed by a multidisciplinary team to assure a positive outcome for the recipient, transplant, and neonate.
Collapse
Affiliation(s)
- Lisa A Coscia
- Transplant Pregnancy Registry International, a division of Gift of Life Institute, Philadelphia, Pennsylvania, USA
| | - Dorothy Kliniewski
- Transplant Pregnancy Registry International, a division of Gift of Life Institute, Philadelphia, Pennsylvania, USA
| | - Serban Constantinescu
- Transplant Pregnancy Registry International, a division of Gift of Life Institute, Philadelphia, Pennsylvania, USA
- Department of Medicine, Section of Nephrology, Hypertension and Kidney Transplantation, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Michael J Moritz
- Transplant Pregnancy Registry International, a division of Gift of Life Institute, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Shah S, Katz-Greenberg G, Gudsoorkar P, Vyas P, Barhorst S, Verma P, Pensak M. Contraceptive Use in Females With Advanced CKD: A Qualitative Study. Kidney Med 2023; 5:100738. [PMID: 38034510 PMCID: PMC10684388 DOI: 10.1016/j.xkme.2023.100738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2023] Open
Abstract
Rationale & Objective Pregnancy in females with kidney disease is not uncommon and is associated with adverse maternal and fetal outcomes. The use of contraception in females with chronic kidney disease remains low. We sought to describe the perspectives of female patients with advanced chronic kidney disease on the use of contraception. Study Design Qualitative study. Setting & Participants We conducted 5 focus group interviews involving 16 adult female patients with advanced chronic kidney disease (n = 3 nondialysis nontransplant chronic kidney disease, n = 9 kidney transplant, and n = 4 kidney failure receiving dialysis) in the United States, following which thematic saturation was reached. Analytical Approach Interview transcripts were analyzed thematically. Results We identified the following 5 themes: 1) variable knowledge regarding reproductive health with kidney disease, 2) inadequate counseling about contraceptive use, 3) lack of interdisciplinary coordination regarding contraceptive use, 4) insufficient educational resources available to guide the contraceptive discussion, and 5) need for research to better understand reproductive needs in females with kidney disease. Limitations Patients were from a single center in the United States, and the study is limited by the transferability of findings to other settings. Conclusions Patients with chronic kidney disease report emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Strategies to strengthen these factors may improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease. Plain-Language Summary Pregnancy in females with kidney disease is common and associated with a higher risk of adverse maternal and fetal outcomes, but the use of contraception remains low. Little is known about female patients' experiences in contraceptive use that may contribute to low contraceptive use in this high-risk population. In the present study using focus group interviews, patients with chronic kidney disease reported emotional challenges with reproductive health, lack of counseling and care coordination, and insufficient resources for contraceptive use. Interventions are needed to strengthen these factors to improve the quality of reproductive care and increase contraceptive use for females with chronic kidney disease.
Collapse
Affiliation(s)
- Silvi Shah
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Goni Katz-Greenberg
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Priyanka Gudsoorkar
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH
| | - Prema Vyas
- Burnett School of Medicine at Texas Christian University, Fort Worth, TX
| | - Sunshine Barhorst
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Prasoon Verma
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Neonatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Meredith Pensak
- Department of Obstetrics and Gynecology, University of Cincinnati, Cincinnati, OH
| |
Collapse
|
4
|
Lau L, Wiebe N, Ramesh S, Ahmed S, Klarenbach S, Carrero JJ, Stenvinkel P, Thorand B, Senior P, Tonelli M, Bello AK. Associations of Estradiol With Mortality and Health Outcomes in Patients Undergoing Hemodialysis: A Prospective Cohort Study. Can J Kidney Health Dis 2023; 10:20543581231209233. [PMID: 37928249 PMCID: PMC10624074 DOI: 10.1177/20543581231209233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/16/2023] [Indexed: 11/07/2023] Open
Abstract
Background Both lower and higher estradiol (E2) levels have been associated with increased mortality among women with kidney failure. However, robust data are still lacking. Objective We investigated the interaction of diabetes and age on linear and nonlinear associations between E2 levels, adverse outcomes, and health-related quality of life (HRQOL) in Canadian women undergoing hemodialysis (HD). Design Population-based cohort study; data from Canadian Kidney Disease Cohort Study (CKDCS). Setting & patients A total of 427 women undergoing HD enrolled in the CKDCS. Measurements Baseline E2 (in pmol/L) and E2 tertiles (<38 pmol/L, 38-95 pmol/L, >95 pmol/L). Methods Cox-proportional hazards used for all-cause and cardiovascular disease (CVD) mortality. Fine-Gray models used for incident CVD. Mixed models used for Health Utilities Index Mark 3 (HUI3), Kidney Disease Quality of Life Physical Component Scores (KDQOL12-PCS), and Mental Component Scores (KDQOL12-MCS). Results Over a median follow-up of 3.6 (interquartile range [IQR]: 1.6-7.5) years, 250 (58.6%) participants died; 74 deaths (29.6%) were CV-related. Among 234 participants without prior CV events, 80 (34.2%) had an incident CVD event. There were no significant linear associations between E2 and all-cause mortality, CVD mortality, and incident CVD. However, E2 showed a significant concave association with all-cause mortality, but not with CVD mortality and incident CVD. Among patients aged ≥63 years, higher E2 levels were associated with lower HUI3 scores, mean difference (MD) = -0.062 per 1 - SD pmol/L, 95% confidence interval (CI) = -0.112 to -0.012, but the opposite was observed in younger patients (<63 years) in whom higher E2 levels were associated with higher HUI3 scores (MD = 0.032 per 1 - SD pmol/L, 95% CI = 0.008-0.055), Pinteraction = .045. No associations were observed among E2, KDQOL12-PCS (MD = -0.15 per 1 - SD pmol/L, 95% CI = -1.15 to 0.86), and KDQOL12-MCS (MD = -0.63 per 1 - SD pmol/L, 95% CI = -1.82 to 0.57). Limitations Unmeasured confounding and small sample size. Conclusions The association between E2 and all-cause mortality may be nonlinear, while no association was observed for CVD mortality, incident CVD, KDQOL12-PCS, and KDQOL12-MCS. Furthermore, the association between serum E2 and HUI3 was modified by age: Higher levels were associated with higher utility among women aged <63 years and the converse observed among older women.
Collapse
Affiliation(s)
- Lina Lau
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- International Helmholtz Research School for Diabetes, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilians Universität München, Germany
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Natasha Wiebe
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Sofia Ahmed
- Department of Medicine, University of Calgary, AB, Canada
| | | | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Peter Stenvinkel
- Renal Unit, Department of Clinical Sciences and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Barbara Thorand
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilians Universität München, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Peter Senior
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - Aminu K. Bello
- Department of Medicine, University of Alberta, Edmonton, Canada
| |
Collapse
|
5
|
Coscia L, Cohen D, Dube GK, Hofmann RM, Moritz MJ, Gattis S, Basu A. Outcomes With Belatacept Exposure During Pregnancy in Kidney Transplant Recipients: A Case Series. Transplantation 2023; 107:2047-2054. [PMID: 37287109 PMCID: PMC10442140 DOI: 10.1097/tp.0000000000004634] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 03/03/2023] [Accepted: 03/10/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Posttransplant fertility returns quickly, and female recipients of child-bearing age may conceive while on immunosuppression. However, pregnancy after transplantation confers risks to the recipient, transplant, and fetus, including gestational hypertension, preeclampsia, gestational diabetes, transplant dysfunction, preterm labor, and low birthweight infants. Additionally, mycophenolic acid (MPA) products are teratogenic. Literature evidence regarding belatacept, a selective T-cell costimulation blocker, during pregnancy and while breastfeeding is extremely limited. When female transplant recipients on a belatacept-based regimen are desirous of pregnancy or at the time of conception, transplant providers manage the immunosuppression regimen in 1 of 2 ways: (1) switch both belatacept and MPA to a calcineurin inhibitor-based regimen with or without azathioprine, which is the more common practice but requires several modifications, having potential negative outcomes; or (2) only switch MPA to azathioprine while continuing belatacept. METHODS This case series includes 16 pregnancies in 12 recipients with exposure to belatacept throughout pregnancy and while breastfeeding. Patient information was obtained from several sources, including Transplant Pregnancy Registry International, providers at Emory University, and Columbia University, as well as literature review. RESULTS Pregnancy outcomes included 13 live births and 3 miscarriages. No birth defects or fetal deaths were reported in any of the live births. Seven infants were breastfed while their mothers continued belatacept. Outcomes appear comparable to those documented with the administration of calcineurin inhibitors. CONCLUSIONS This case series provides data supporting the continued administration of belatacept during pregnancy. Additional research will assist in developing better guidelines to counsel female transplant recipients on belatacept desiring to pursue pregnancy.
Collapse
Affiliation(s)
- Lisa Coscia
- Transplant Pregnancy Registry International, Philadelphia, PA
| | - David Cohen
- Department of Medicine, Columbia University, New York, NY
| | | | - R. Michael Hofmann
- Department of Medicine, Trinity Health Kidney Transplant Center, Grand Rapids, MI
| | - Michael J. Moritz
- Transplant Pregnancy Registry International, Philadelphia, PA
- Surgery, Lehigh Valley Health Network, Allentown, PA
- Department of Surgery, Morsani College of Medicine, Tampa, FL
| | - Sara Gattis
- Department of Pharmacy, Emory University School of Medicine, Atlanta, GA
| | - Arpita Basu
- Department of Medicine, Division of Nephrology and Division of Transplant, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
6
|
Huang H, Liu X, Lin X, Wu X, Qiu Y, Huang H. Successful pregnancies in post-kidney transplant couples: four case reports. Front Immunol 2023; 14:1215480. [PMID: 37503336 PMCID: PMC10368990 DOI: 10.3389/fimmu.2023.1215480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/01/2023] [Indexed: 07/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Hao Huang
- Department of Rehabilitation Medicine, Renji College of Wenzhou Medical University, Wenzhou, China
| | - Xinyu Liu
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Nephropathy, Hangzhou, Zhejiang, China
- Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Xiaoli Lin
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Nephropathy, Hangzhou, Zhejiang, China
- Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Xiaoying Wu
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Nephropathy, Hangzhou, Zhejiang, China
- Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Yingyin Qiu
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Nephropathy, Hangzhou, Zhejiang, China
- Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Hongfeng Huang
- Kidney Disease Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Nephropathy, Hangzhou, Zhejiang, China
- Institute of Nephropathy, Zhejiang University, Hangzhou, China
| |
Collapse
|
7
|
Jethwani P. Overview of Renal Transplantation for Primary Care Physicians: Workup, Complications, and Management. Med Clin North Am 2023; 107:707-716. [PMID: 37258008 DOI: 10.1016/j.mcna.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Kidney transplantation remains the treatment of choice for eligible patients with end-stage kidney disease. The last few decades have seen an expansion in the transplant recipient pool with over 250,000 patients living with a kidney transplant today. Because of limited bandwidth for ongoing follow-up and management of chronic medical conditions, transplant centers are directing more and more patients back to their general nephrologists and primary care doctors for longitudinal care. As a result, it is becoming increasingly important for primary care physicians to have a nuanced understanding of medications, complications, and chronic medical problems unique to transplant recipients. This article reviews the role of the primary care office in helping streamline the pretransplant evaluation process and long-term posttransplant care.
Collapse
Affiliation(s)
- Priyanka Jethwani
- James D Eason Transplant Institute, Methodist University Hospital, 1265 Union Avenue, Memphis, TN 38104, USA; Department of Surgery, University of Tennessee Health Sciences Center, 1211 Union Avenue, Memphis, TN 38104, USA.
| |
Collapse
|
8
|
Bosch A, Daniel KE. Pregnancy and contraception in the post-liver transplant patient. Clin Liver Dis (Hoboken) 2023; 21:187-190. [PMID: 37361256 PMCID: PMC10287116 DOI: 10.1097/cld.0000000000000059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 04/04/2023] [Indexed: 06/28/2023] Open
|
9
|
FSRH Guideline (March 2023) Intrauterine contraception. BMJ SEXUAL & REPRODUCTIVE HEALTH 2023; 49:1-142. [PMID: 37188461 DOI: 10.1136/bmjsrh-2023-iuc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
|
10
|
Sawinski D, Ralston SJ, Coscia L, Klein CL, Wang EY, Porret P, O'Neill K, Iltis AS. Counselling, Research Gaps, and Ethical Considerations Surrounding Pregnancy in Solid Organ Transplant Recipients. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:89-99. [PMID: 36472763 DOI: 10.1007/s11673-022-10219-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 07/09/2022] [Indexed: 05/04/2023]
Abstract
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.
Collapse
Affiliation(s)
- Deirdre Sawinski
- Nephrology and Transplantation, Weill Cornell Medical College, New York, NY, USA.
| | - Steven J Ralston
- Department of Obstetrics and Gynecology, Pennsylvania Hospital, Philadelphia, PA, USA
| | - Lisa Coscia
- Gift of Life Institute, Transplant Pregnancy Registry (TPR) International, Philadelphia, PA, USA
| | - Christina L Klein
- Department of Transplantation, Piedmont Transplant Institute, Piedmont Atlanta Hospital, Atlanta, GA, USA
| | - Eileen Y Wang
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Paige Porret
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kathleen O'Neill
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Ana S Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA
| |
Collapse
|
11
|
McIntosh T, Puerzer P, Li MT, Malat G, Sammons C, Norris M, Fallah T, Trofe-Clark J, DuBois JM, Iltis A, Mohan S, Sawinski D. A survey of solid organ transplant recipient attitudes and concerns regarding contraception and pregnancy. Clin Transplant 2023; 37:e14948. [PMID: 36822220 DOI: 10.1111/ctr.14948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Many women who are solid organ transplant (SOT) recipients wish to have children after transplantation. Contraception is an important component of post-transplant planning and care, given the increased risk associated with post-transplant pregnancies. We sought to understand patient attitudes and concerns about post-transplant contraception and pregnancy. METHODS Following a comprehensive literature review, our team developed a survey that was administered to female SOT recipients of childbearing age. We used descriptive and inferential statistics to characterize participant views RESULTS: A total of 243 transplant recipients completed the survey (80.7% response rate). The mean age of respondents was 37.5 years (±8.1 years), 66.7% were kidney recipients, and 40.7% were within the first year after transplant. The most common concerns among respondents included fetal and maternal health complications. Participants generally did not agree that transplant recipients should be advised to avoid pregnancy. There was strong support for shared decision-making about pregnancy after transplantation CONCLUSION: Understanding patient perspectives can help transplant providers make better care recommendations and support patient autonomy in reproductive decisions post-transplant. Given that there are some differences in views by transplant type, individualized conversations between patients and providers are needed.
Collapse
Affiliation(s)
- Tristan McIntosh
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Payton Puerzer
- School of Arts and Sciences, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Miah T Li
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, NY, New York, USA
| | - Gregory Malat
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chelsea Sammons
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maxwell Norris
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tara Fallah
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Trofe-Clark
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Renal, Electrolyte, and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Department of Surgery, Division of Transplantation, Perelman School of Medicine, University of Pennsylvania, Pennsylvania, USA
| | - James M DuBois
- Bioethics Research Center, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Ana Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Vagelos College of Physicians and Surgeons, NY, New York, USA
| | - Deirdre Sawinski
- Weill Cornell Medical College, Department of Medicine, Division of Nephrology and Transplantation, New York, New York, USA
| |
Collapse
|
12
|
Supporting Reproductive Care for Patients Requiring Solid Organ Transplant. Nurs Womens Health 2023; 27:53-64. [PMID: 36567068 DOI: 10.1016/j.nwh.2022.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/09/2022] [Indexed: 12/24/2022]
Abstract
After a solid organ transplant, individuals have the capability to maintain a successful pregnancy. However, many posttransplant pregnancies are unintended, thereby posing risks to health. There is a critical need to strengthen patient education regarding safe approaches to conception, general reproductive health, and childbearing capabilities. The complex needs of patients after transplant, including management of graft health and medication regimens, may distract from the usual reproductive care offered to other individuals of childbearing potential. Thorough education about immunosuppressant medications, contraceptive methods, and expected waiting periods before conceiving are essential. Nurses can work with each individual and direct the interprofessional health care team to provide effective, safe, comprehensive, and inclusive reproductive care to patients posttransplant.
Collapse
|
13
|
Shingina A, Sarkar M, Feld L. On the Importance of Safe Access to Reproductive Options for Adolescents and Women With Liver Disease. Gastroenterology 2022; 163:792-794. [PMID: 35752297 DOI: 10.1053/j.gastro.2022.06.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/14/2022] [Accepted: 06/17/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Alexandra Shingina
- Division of Gastroenterology, Hepatology and Nutrition, Faculty of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Monika Sarkar
- Division of GI/Hepatology, University of California, San Francisco, San Francisco, California
| | - Lauren Feld
- Division of Gastroenterology & Hepatology, University of Washington, Seattle, Washington
| |
Collapse
|
14
|
Prokopenko EI, Guryeva VM, Petrukhin VA, Krasnopol’skaya KV, Burumkulova FF, Gubina DV. IVF pregnancy after kidney transplantation: clinical case and literature review. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022. [DOI: 10.15825/1995-1191-2022-4-15-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Kidney transplantation (KT), the optimal treatment for stage 5 chronic kidney disease (CKD), restores impaired fertility in most women of reproductive age. However, infertility occurs in some patients after successful KT. We present our own experience of overcoming secondary tubal infertility by in vitro fertilization (IVF). The patient was a 36-year-old with a transplanted kidney, who had lost two pregnancies in the past due to severe preeclampsia (PE). After the second attempt on cryo-thawed embryo transfer against the background of hormone replacement therapy, one embryo was transferred into the uterus, resulting in pregnancy. Gestational diabetes mellitus (GDM) was diagnosed in the first trimester, and a diet was prescribed. Immunosuppression with tacrolimus, azathioprine and methylprednisolone, prophylaxis of PE with low molecular weight heparin and antiplatelet drugs were administered during pregnancy. Elective cesarean section was performed at 37–38 weeks and a healthy boy was born, weighing 2760 g (25th percentile), 48 cm tall (36th percentile). A stay in the neonatal intensive care unit was not required. The baby is growing and developing normally, the mother’s renal graft function is satisfactory. So, IVF can be successfully used in post-KT patients with infertility issues, provided that the IVF program is carefully controlled, and the pregnancy is managed in a multidisciplinary manner.
Collapse
Affiliation(s)
- E. I. Prokopenko
- Vladimirsky Moscow Regional Research Clinical Institute; Moscow Regional Research Institute of Obstetrics and Gynecology
| | - V. M. Guryeva
- Moscow Regional Research Institute of Obstetrics and Gynecology
| | - V. A. Petrukhin
- Moscow Regional Research Institute of Obstetrics and Gynecology
| | | | | | - D. V. Gubina
- Vladimirsky Moscow Regional Research Clinical Institute
| |
Collapse
|
15
|
Sousa BRDM, Gomes HKO, de Sousa MV, Mazzali M. Sexual and Reproductive Health Assessment in a Group of Female Renal Transplant Recipients. Transplant Proc 2022; 54:1286-1289. [PMID: 35618523 DOI: 10.1016/j.transproceed.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/02/2022] [Accepted: 03/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fertility and sexual health are impaired in individuals with chronic kidney disease and can be restored after a successful renal transplant. This is a single-center prospective study about the sexual and reproductive health (including contraceptive methods and gynecologic cancer screening) in renal transplant recipients. METHODS Female renal transplant recipients, aged 18 to 49 years at transplant, were interviewed about their gynecologic history, sexual health, and use of contraceptive methods. RESULTS Ninety-one patients fulfilled the inclusion criteria. The majority of women maintained menstrual cycles during dialysis therapy, being almost 60% of the women in an irregular rhythm. Pregnancies were reported for 51 women, 20% after transplant, and associated with low-weight newborns. The incidence of spontaneous abortion was 12.5%. Thirty-one patients were denied contraceptive methods due to the vasectomy of the partner (n = 16) or the belief that they would not become pregnant (n = 15). The most common contraceptive method was a condom, and the use of an intrauterine device was rare. Gynecologic assessment and cancer screening were out-of-date in almost one-third of patients. CONCLUSIONS In this study, the majority of women were from low-income areas and had low levels of education. Despite access to public universal health care, adherence to yearly screening tests and use of contraceptive methods were lower than expected.
Collapse
Affiliation(s)
- Bruna Ranyelle de Marinho Sousa
- Renal Transplant Research Laboratory, Renal Transplant Unit, Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Hellen Karoline Oliveira Gomes
- Renal Transplant Research Laboratory, Renal Transplant Unit, Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Marcos Vinicius de Sousa
- Renal Transplant Research Laboratory, Renal Transplant Unit, Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil.
| | - Marilda Mazzali
- Renal Transplant Research Laboratory, Renal Transplant Unit, Division of Nephrology, Department of Internal Medicine, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| |
Collapse
|
16
|
Abstract
Placed in a historical context, this overview focuses on post-transpant pregnancy, fatherhood, and contraception in women and men. The critical importance of early reproductive counseling because of improved sexual function and the early return of ovulation and menses post-transplant is emphasized. We explain the decision making regarding contraception choices. The available data on the safety of immunosuppressive drugs in pregnancy, and for men desiring fatherhood, are detailed. The risk of maternal ingestion of mycophenolate products on the in utero fetus is considered and contrasted with the lack of concern for their use by men fathering children. Pregnancy risks to the allograft, baby, and mother are discussed. An infant's exposure to specific immunosuppressant medications through breastfeeding is reviewed. The ethics and realities of post-transplant parenthood are explored.
Collapse
Affiliation(s)
- Christina L. Klein
- Piedmont Transplant Institute, Piedmont Healthcare Inc., Atlanta, Georgia
| | - Michelle A. Josephson
- Section of Nephrology, Division of Biological Sciences, University of Chicago, Chicago, Illinois
| |
Collapse
|
17
|
Stanic Z, Vulic M, Hrgovic Z, Fureš R, Plazibat M, Cecuk E, Vusic I, Lagancic M. Pregnancy After Simultaneous Pancreas-Kidney Transplantation in Treatment of End-Stage Diabetes Mellitus: a Review. Z Geburtshilfe Neonatol 2021; 226:86-91. [PMID: 34933349 DOI: 10.1055/a-1710-4097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The majority of patients with simultaneous pancreas and kidney transplant (SPKT) required transplantation owing to a long-standing history of insulin-dependent diabetes mellitus (IDDM). The disease causes multiple organ damage, impairs fertility, and affects quality of life. A successful kidney and pancreas transplant can improve health, ameliorate the consequences of pre-existent diabetes, and restore fertility. Good graft function, without any sign of rejection, and stable doses of immunosuppressant drugs are of utmost importance prior to the planned pregnancy. SPKT recipients who become pregnant may be at an increased risk for an adverse outcome and require meticulous multidisciplinary surveillance. We present experiences with SPKT pregnancies, traditional approaches, and recent considerations. In light of complex interactions between new anatomic relations and the impact of developing pregnancy and immunosuppressive medications, special stress is put on the risk of graft rejection, development of pregnancy complications, and potential harmful effects on fetal development. Recent recommendations in management of SPKT recipients who wish to commence pregnancy are presented as well. Key words: transplantation, pregnancy, pancreas, kidney, simultaneous pancreas and kidney transplantation (SPKT).
Collapse
Affiliation(s)
- Zana Stanic
- Department for Integrative Gynecology, Obstetrics and Minimally invasive Gynecologic Surgery, Zabok General Hospital, Zabok, Croatia
| | - Marko Vulic
- Department of Gynaecology and Obstetrics, Clinical Hospital Center Split, Split, Croatia
| | - Zlatko Hrgovic
- Gynecology and Women's Health Department, Goethe-Universität Frankfurt am Main, Frankfurt am Main, Germany
| | - Rajko Fureš
- Department for Integrative Gynecology, Obstetrics and Minimally invasive Gynecologic Surgery, Zabok General Hospital, Zabok, Croatia
| | - Milvija Plazibat
- Department of Pediatrics, Zabok General Hospital, Zabok, Croatia
| | - Esma Cecuk
- Center for transfusion and transplant medicine, Clinical Hospital Center Split, Split, Croatia
| | - Iva Vusic
- Emergency Department, Bjelovar General Hospital, Bjelovar, Croatia
| | - Marko Lagancic
- Emergency Department, Dubrava Clinical Hospital, Zagreb, Croatia
| |
Collapse
|
18
|
Iltis AS, Mehta M, Sawinski D. Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease. HEC Forum 2021:10.1007/s10730-021-09463-7. [PMID: 34617168 DOI: 10.1007/s10730-021-09463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.
Collapse
Affiliation(s)
- Ana S Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA.
| | - Maya Mehta
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA
| | - Deirdre Sawinski
- Renal Electrolyte, and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
19
|
Gastañaga-Holguera T, Calvo M, Gómez-Irwin L, Gesto IC, González-González V, Vidaurreta M. Successful pregnancy and follow-up after in vitro fertilization of a kidney transplant patient with systemic lupus erythematosus, primary biliary cholangitis, and hypothyroidism. JBRA Assist Reprod 2021; 25:657-660. [PMID: 34415135 PMCID: PMC8489825 DOI: 10.5935/1518-0557.20210052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This report describes the case of a female kidney transplant patient with systemic lupus erythematosus, primary biliary cholangitis, and postsurgical hypothyroidism due to Grave's disease who had a healthy newborn after in vitro fertilization (IVF). Cases of successful pregnancy involving women who underwent IVF after kidney transplantation have been reported. Normal and stable renal function, adequate immunosuppressant therapy, and well-managed blood pressure are requirements to be eligible for IVF and pregnancy. Primary biliary cholangitis without cirrhosis does not seem to worsen during pregnancy and IVF must be individualized in patients with systemic lupus erythematosus. There are no similar case reports involving kidney transplant patients or individuals with autoimmune disorders, so the decision to perform IVF had to be individualized in order to avoid complications for the mother and fetus.
Collapse
Affiliation(s)
| | - Marta Calvo
- Assisted Reproduction Department. Hospital Clinico San Carlos, Madrid, Spain
| | - Laura Gómez-Irwin
- Gastroenterology Department. Hospital Universitario de Cruces, Bizkaia, Spain
| | - Isabel Campo Gesto
- Prenatal Diagnosis Department. Hospital Clinico San Carlos, Madrid, Spain
| | | | - Marta Vidaurreta
- Assisted Reproduction Department. Hospital Clinico San Carlos, Madrid, Spain
| |
Collapse
|
20
|
Ponticelli C, Zaina B, Moroni G. Planned Pregnancy in Kidney Transplantation. A Calculated Risk. J Pers Med 2021; 11:jpm11100956. [PMID: 34683097 PMCID: PMC8537874 DOI: 10.3390/jpm11100956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022] Open
Abstract
Pregnancy is not contraindicated in kidney transplant women but entails risks of maternal and fetal complications. Three main conditions can influence the outcome of pregnancy in transplant women: preconception counseling, maternal medical management, and correct use of drugs to prevent fetal toxicity. Preconception counseling is needed to prevent the risks of an unplanned untimely pregnancy. Pregnancy should be planned ≥2 years after transplantation. The candidate for pregnancy should have normal blood pressure, stable serum creatinine <1.5 mg/dL, and proteinuria <500 mg/24 h. Maternal medical management is critical for early detection and treatment of complications such as hypertension, preeclampsia, thrombotic microangiopathy, graft dysfunction, gestational diabetes, and infection. These adverse outcomes are strongly related to the degree of kidney dysfunction. A major issue is represented by the potential fetotoxicity of drugs. Moderate doses of glucocorticoids, azathioprine, and mTOR inhibitors are relatively safe. Calcineurin inhibitors (CNIs) are not associated with teratogenicity but may increase the risk of low birth weight. Rituximab and eculizumab should be used in pregnancy only if the benefits outweigh the risk for the fetus. Renin-angiotensin system inhibitors, mycophenolate, bortezomib, and cyclophosphamide can lead to fetal toxicity and should not be prescribed to pregnant women.
Collapse
Affiliation(s)
- Claudio Ponticelli
- Nephrology, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Barbara Zaina
- Department of Obstetrics and Gynecology, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gabriella Moroni
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, 20122 Milan, Italy;
| |
Collapse
|
21
|
Punjala SR, Phillips BL, Chowdhury P, Pile T, Karydis N, Kessaris N, Olsburgh J, Harding K, Callaghan CJ, Nelson-Piercy C, Drage M. Outcomes of pregnancy in simultaneous pancreas and kidney transplant recipients: A single-center retrospective study. Clin Transplant 2021; 35:e14435. [PMID: 34292634 DOI: 10.1111/ctr.14435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 11/28/2022]
Abstract
Simultaneous pancreas and kidney (SPK) transplantation, in uremic women with insulin-dependent diabetes, increases the chance of a successful pregnancy and minimizes the risk to infants. The aim of this study was to document pregnancy and explore the challenges in this cohort of women. Retrospective analysis of women who underwent pancreas transplantation between January 1, 1998 and 8 January, 2019 was conducted. Seventeen pregnancies were identified in 13 women. Mean transplant-to-pregnancy interval was 4.6 years (range, 1.1-10.2 years). Eleven pregnancies resulted in live birth (65%), and six (35%) ended in miscarriage/fetal loss at a median gestational age of 8.5 weeks. Mean gestational age at delivery was 34.9 weeks (SD ±3 weeks). Preeclampsia and C-section rates were 77% and 67%, respectively. Adverse fetal and graft outcomes were observed in 100% of unplanned pregnancies, compared to 10% of planned pregnancies (P < .001). One kidney allograft was lost during pregnancy; one pancreas and two kidney allografts were lost within 3 years of pregnancy. This is a high-risk group for grafts and offspring. Pre-pregnancy planning is vital. A multidisciplinary approach by obstetric and transplant teams is important pre-pregnancy, antenatally, and peripartum. This is the largest published series of pregnancies in SPK recipients from a single center.
Collapse
Affiliation(s)
- Sai Rithin Punjala
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Benedict Lyle Phillips
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paramit Chowdhury
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Taryn Pile
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nikolaos Karydis
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nicos Kessaris
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jonathon Olsburgh
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kate Harding
- Women's Services Directorate, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Chris J Callaghan
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Martin Drage
- Department of Nephrology and Transplantation, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
22
|
Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update. TRANSPLANTOLOGY 2021. [DOI: 10.3390/transplantology2020010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Sexual life and fertility are compromised in end stage kidney disease both in men and in women. Successful renal transplantation may rapidly recover fertility in the vast majority of patients. Pregnancy modifies anatomical and functional aspects in the kidney and represents a risk of sensitization that may cause acute rejection. Independently from the risks for the graft, pregnancy in kidney transplant may cause preeclampsia, gestational diabetes, preterm delivery, and low birth weight. The nephrologist has a fundamental role in correct counseling, in a correct evaluation of the mother conditions, and in establishing a correct time lapse between transplantation and conception. Additionally, careful attention must be given to the antirejection therapy, avoiding drugs that could be dangerous to the newborn. Due to the possibility of medical complications during pregnancy, a correct follow-up should be exerted. Even if pregnancy in transplant is considered a high risk one, several data and studies document that in the majority of patients, the long-term follow-up and outcomes for the graft may be similar to that of non-pregnant women.
Collapse
|
23
|
Choudhary NS, Saraf N, Saigal S, Soin AS. Long-term Management of the Adult Liver Transplantation Recipients. J Clin Exp Hepatol 2021; 11:239-253. [PMID: 33746450 PMCID: PMC7953009 DOI: 10.1016/j.jceh.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/14/2020] [Indexed: 12/12/2022] Open
Abstract
The survival of liver transplantation (LT) recipients has been improved remarkably in short-term. The major causes of mortality in long-term include nonimmunological causes such as cardiovascular, de novo malignancy, chronic kidney disease, and recurrence of primary disease. Rejection-related mortality is rare in the long-term after LT. We discuss nonrejection causes of long-term morbidity/mortality, risk factors, and management strategies in LT recipients. In addition, we discuss osteoporosis, contraception, and pregnancy in LT recipients.
Collapse
Key Words
- AIH, autoimmune hepatitis
- BMI, body mass index
- CKD, chronic kidney disease
- CNI, calcineurin inhibitors
- CVD, cardiovascular disease
- DDLT, deceased donor liver transplantation
- DM, diabetes mellitus
- DNM, de novo malignancy
- HCV, hepatitis C virus
- HR, hazard ratio
- IUCD, Intrauterine contraceptive devices
- LDLT, living donor liver transplantation
- LT, liver transplantation
- MDRD, Modification of Diet in Renal Disease
- MMF, mycophenolate
- MS, metabolic syndrome
- NAFLD, nonalcoholic fatty liver disease
- NASH, nonalcoholic steatohepatitis
- OR, odds ratio
- PBC, primary biliary cholangitis
- PSC, primary sclerosing cholangitis
- PTDM, posttransplantation diabetes mellitus
- PTMS, posttransplantation metabolic syndrome
- SVR, sustained virological response
- cardiovascular disease
- de novo malignancy
- eGFR, estimated glomerular filtration rate
- mTORi, Mammalian target of rapamycin inhibitors
- osteoporosis
- pregnancy
- recurrence
Collapse
Affiliation(s)
- Narendra S. Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Sanjiv Saigal
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| | - Arvinder S. Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta The Medicity, Gurgaon, Delhi (NCR), India
| |
Collapse
|
24
|
Ardura MI, Coscia LA, Meyers MR. Promoting safe sexual practices and sexual health maintenance in pediatric and young adult solid organ transplant recipients. Pediatr Transplant 2021; 25:e13949. [PMID: 33491268 DOI: 10.1111/petr.13949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/01/2020] [Accepted: 12/02/2020] [Indexed: 12/17/2022]
Abstract
The majority of Americans make their sexual debut during their adolescent years. Preventing pregnancy and STI during this period is vital to ensuring health and safety. As survival has improved after pediatric SOT, chronically immunosuppressed adolescents seek guidance in their medical home on matters of sexual health. Transplant practitioners often do not feel equipped to fully address these needs. This review serves as an introductory sexual preventive care resource for adolescent and young adult (AYA) SOT recipients. First, we review data on safety, efficacy, and use of contraceptive options currently available for transplant recipients with child-bearing potential. Then, we suggest a personalized sexual health discussion focusing on the diagnosis and prevention of STIs in adolescent and young adult transplant recipients. Finally, we present recommendations for STI screening of asymptomatic patients, use of index of suspicion and diagnostic testing in symptomatic patients, and opportunities to optimize STI prevention strategies. Data compiled from studies of adult SOT recipients, general population studies, and published guidelines are often extrapolated for use, as limited data exist in AYA SOT recipients. This informational dearth underscores the need for future research to better characterize the unique needs of AYA SOT recipients.
Collapse
Affiliation(s)
- Monica I Ardura
- Pediatric Infectious Diseases & Host Defense, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Lisa A Coscia
- Transplant Pregnancy Registry International, Philadelphia, PA, USA
| | - Melissa R Meyers
- Pediatric Nephrology, Children's National Health System, Washington, DC, USA
| |
Collapse
|
25
|
Sarkar M, Brady CW, Fleckenstein J, Forde KA, Khungar V, Molleston JP, Afshar Y, Terrault NA. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 73:318-365. [PMID: 32946672 DOI: 10.1002/hep.31559] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Monika Sarkar
- University of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Jean P Molleston
- Indiana University and Riley Hospital for Children, Indianapolis, IN
| | - Yalda Afshar
- University of California, Los Angeles, Los Angeles, CA
| | - Norah A Terrault
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| |
Collapse
|
26
|
Gonzalez Suarez ML, Parker AS, Cheungpasitporn W. Pregnancy in Kidney Transplant Recipients. Adv Chronic Kidney Dis 2020; 27:486-498. [PMID: 33328065 DOI: 10.1053/j.ackd.2020.06.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 11/11/2022]
Abstract
Women with end-stage kidney disease commonly have difficulty conceiving through spontaneous pregnancy, and many suffer from infertility. Kidney transplantation restores the impairment in fertility and increases the possibility of pregnancy. In addition, the number of female kidney transplant recipients of reproductive age has been increasing. Thus, preconception counseling, contraceptive management, and family planning are of great importance in the routine care of this population. Pregnancy in kidney transplant recipients is complicated by underlying maternal comorbidities, kidney allograft function, the effect of pregnancy on the transplanted kidney, and the effect of the maternal health on the fetus, in addition to immunosuppressive medications and their potential teratogenesis. Given the potential maternal and fetal risks, and possible complications during pregnancy, pretransplant and prepregnancy counseling for women of reproductive age are crucial, including delivery of information regarding contraception and timing for pregnancy, fertility and pregnancy rates, the risk of immunosuppression on the fetus, the risk of kidney allograft, and other maternal complications. In this article, we discuss aspects related to pregnancy among kidney transplant recipients and their management.
Collapse
|
27
|
Singh M. Breastfeeding and Medication Use in Kidney Disease. Adv Chronic Kidney Dis 2020; 27:516-524. [PMID: 33328068 PMCID: PMC7211684 DOI: 10.1053/j.ackd.2020.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 12/23/2022]
Abstract
Pregnancy in CKD is a condition fraught with challenges including multiple medications, high-risk pregnancy followed by maternal and fetal compromise such as preterm delivery, and low birth weight infant. Breastfeeding is unique in its impact on the mother and the baby, their bonding, and future health implications impacting the society. Breast milk is produced specific for the infant by the biological mother. It changes in composition with lactation stage and leads to optimal growth of the baby including establishing circadian rhythms, getting protective antibodies, and establishing a healthy gut microbiome. Multiple hormones influence the composition of the milk. Lactation is maintained by removal of the milk. Blood-milk barrier allows for the specific composition of milk by transporting different sized molecules through different mechanisms. It is safe to assume that most medications will be found in some amount in human milk; however, the impact of that is usually not enough to justify stopping breastfeeding. When the mother's milk is not available, formula or donor milk can be considered. There are resources to guide the use of medications during lactation that the providers should be aware of and use, to guide medication and breastfeeding recommendations.
Collapse
|
28
|
Ritchie J, Seidman D, Srisengfa Y, Perito ER, Sarkar M. Family Planning in Liver Transplant: Patient and Provider Knowledge and Practices. Liver Transpl 2020; 26:1233-1240. [PMID: 32583555 DOI: 10.1002/lt.25835] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/06/2020] [Accepted: 05/13/2020] [Indexed: 12/31/2022]
Abstract
Fertility is often impaired in adolescents and women with cirrhosis, but it is rapidly restored after liver transplantation (LT). Early and unplanned pregnancies confer increased risks to maternal, fetal, and graft health, underscoring the need for reproductive counseling. However, data on reproductive practices or counseling in the LT setting are limited. An anonymous online Qualtrics (Provo, UT) survey was sent to transplant patients and providers to gauge knowledge and practices surrounding contraception and pregnancy. Eligible participants included transplant patients aged 14-45 years and their transplant providers. Patient response was 50.0% (74/148), 14 of whom were pre-LT patients and 60 of whom were post-LT patients. Counseling occurred in 37% of patients prior to transplant and 82% after transplant. Most patients (86%) considered family planning a high priority in their transplant care. Contraception- and pregnancy-specific counseling was provided by LT providers in 60% and 44% of patients, respectively. The most desired mode of counseling by patients was in-person discussion with an LT provider (89%). Despite most post-LT patients receiving counseling, only 41% used contraception during the first year after LT, of whom 32% relied on high failure methods. Of the 31/43 (72.1%) provider responses, 96% voiced interest in additional reproductive education. Most providers (90%) correctly advised that patients delay pregnancy during the first year after LT, although misconceptions about safety of estrogen and intrauterine devices were selected by 53% and 42%, respectively. Some favored resources by providers were educational pamphlets in clinic (88%) and automated note templates to prompt family planning inquiry (72%). Transplant patients and providers have key deficiencies in their knowledge of contraception and corresponding practices. Most post-LT patients receive counseling, yet contraception practices are inadequate for preventing unplanned pregnancy. Discussion with transplant providers was the most favored counseling modality by patients, underscoring our critical role in optimizing post-LT reproductive care.
Collapse
Affiliation(s)
- Julia Ritchie
- Department of Obstetrics and Gynecology, Saint Luke's University, Bethlehem, PA
| | - Dominika Seidman
- Department of Obstetrics and Gynecology, University of California, San Francisco, San Francisco, CA
| | - Yanin Srisengfa
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - Emily R Perito
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of California, San Francisco, San Francisco, CA
| | - Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| |
Collapse
|
29
|
Sarkar M, Sawinski D, Coscia L. Pregnancy in Liver Transplantation. Liver Transpl 2020; 26:954-955. [PMID: 32170779 DOI: 10.1002/lt.25753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/05/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Monika Sarkar
- Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA
| | - Deirdre Sawinski
- Division of Nephrology, University of Pennsylvania, Philadelphia, PA
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA
| | | |
Collapse
|
30
|
Phillips PK, Saha S, Foley DP, Iruretagoyena JI, Said A. Deficiencies in reproductive health counseling in liver transplant recipients. Clin Transplant 2019; 33:e13631. [PMID: 31173406 DOI: 10.1111/ctr.13631] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 05/16/2019] [Accepted: 06/04/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND In liver transplant (LT) recipients of childbearing age, there is often rapid return of fertility post-transplant. Our aim was to determine whether healthcare providers are documenting reproductive health counseling in LT recipients. METHODS We performed a review of 365 LT recipients (164 female, 201 male) of childbearing age transplanted between 1994 and 2015 at a single center. We evaluated documentation of reproductive health counseling, content of the counseling and its provider. RESULTS Reproductive health counseling was documented in 7% of LT recipients (14% of females, 0.5% of males). The transplant team provided the counseling in 56%, obstetrics/gynecology in 35%, and primary care in 9%. Twenty-four post-LT pregnancies occurred; these were unplanned in 13%. Miscarriage/stillbirth occurred in 7/24 pregnancies (29%). Mycophenolic acid was used by 20% of female recipients at conception. Only age at transplant (P = 0.001) and post-LT pregnancy was associated with documentation of reproductive health counseling in female recipients (P = 0.0001). CONCLUSION Despite rapid return of fertility in reproductive-aged LT recipients, documentation of reproductive health counseling in this population is rare in men and women. This increases the potential for adverse maternal and fetal outcomes in this high-risk population.
Collapse
Affiliation(s)
- Paulina K Phillips
- Division of Gastroenterology and Hepatology, Wm S Middleton VAMC Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Sumona Saha
- Division of Gastroenterology and Hepatology, Wm S Middleton VAMC Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - David P Foley
- Division of Transplantation, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jesus I Iruretagoyena
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Adnan Said
- Division of Gastroenterology and Hepatology, Wm S Middleton VAMC Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| |
Collapse
|
31
|
Abstract
Liver diseases during pregnancy pose a unique clinical challenge because they can affect the lives of both the mother and unborn child. Although severe liver disease is rare, pregnancy-related liver disease affects approximately 3% of pregnancies and can be fatal. Timely recognition and diagnosis are essential in order to institute appropriate management strategies. This article provides an overview of liver diseases during pregnancy and is divided into 2 sections: (1) liver diseases specific to pregnancy, and (2) preexisting or coincident liver diseases during pregnancy.
Collapse
Affiliation(s)
- Karen Ma
- Section of Gastroenterology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 207, Chicago, IL 60612, USA
| | - Daniel Berger
- Section of Gastroenterology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 207, Chicago, IL 60612, USA
| | - Nancy Reau
- Section of Hepatology, Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, 1725 West Harrison Street, Suite 319, Chicago, IL 60612, USA.
| |
Collapse
|
32
|
Yaprak M, Doğru V, Sanhal CY, Özgür K, Erman M. In Vitro Fertilization After Renal Transplantation: A Single-Center Experience. Transplant Proc 2019; 51:1089-1092. [PMID: 31101177 DOI: 10.1016/j.transproceed.2019.01.105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Although kidney transplantation often increases the chances of fertility, the rate of infertile patients is still high. In vitro fertilization promises successful results for infertile renal transplantation patients. The purpose of this study was to analyze the experience of a single center. METHODS Patients were invited to complete a survey for their obstetric history. Documentation review included demographic and clinical characteristics of patients, like procedure records, follow-up complications, immunosuppression maintenance protocols, and pregnancy outcomes. RESULTS Thirteen patients were reached to complete the survey. The mean age of patients was 33 ± 4 years at in vitro fertilization (IVF). The median duration of infertility was 2 years. Twenty-four IVF sessions were applied to these 13 women with renal transplantation. The procedure failed in 13 of these sessions; and 8 women achieved 11 clinical pregnancies. There were 3 miscarriages and 2 stillbirths. Six women had live births with no neonatal deaths. One patient had a graft rejection after the IVF procedure. Serum creatinine level increased more than 30% in 3 patients after the IVF procedure, while 9 patients had a minimal or no change. DISCUSSION In our study, we evaluated the records of 13 patients with renal transplantation who had IVF procedures. Fortunately, more than half of these patients had live births with no neonatal deaths. In our opinion, our findings show that IVF procedures can be accepted as a promising method in patients with renal transplantation and need a therapy for fertility. Moreover, a 25% live-birth rate per procedure is also a satisfactory result.
Collapse
Affiliation(s)
- M Yaprak
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey.
| | - V Doğru
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey
| | - C Y Sanhal
- Department of Obstetrics and Gynecology, Akdeniz University Hospital, Antalya, Turkey
| | - K Özgür
- Antalya IVF, Antalya, Turkey
| | - M Erman
- Department of Obstetrics and Gynecology, Akdeniz University Hospital, Antalya, Turkey
| |
Collapse
|
33
|
Etta P. Comprehensive management of the renal-transplant recipient. INDIAN JOURNAL OF TRANSPLANTATION 2019. [DOI: 10.4103/ijot.ijot_25_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
34
|
Abstract
Improved understanding of the pathogenesis and natural history of many urologic disorders, as well as advances in fertility preservation techniques, has increased the awareness of and options for management of fertility threats in pediatric patients. In children, fertility may be altered by oncologic conditions, by differences in sexual differentiation, by gonadotoxic drugs and other side effects of treatment for nonurologic disorders, and by urologic conditions, such as varicocele and cryptorchidism. Although fertility concerns are best addressed in a multidisciplinary setting, pediatric urologists should be aware of the underlying pathophysiology and management options to properly counsel and advocate for patients.
Collapse
Affiliation(s)
- Kathleen Kieran
- Division of Urology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.220, Seattle, WA 98105, USA.
| | - Margarett Shnorhavorian
- Division of Urology, Seattle Children's Hospital, 4800 Sand Point Way Northeast, OA.9.220, Seattle, WA 98105, USA
| |
Collapse
|