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.

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).

Maternal, Decidual, and Neonatal Lymphocyte Composition Is Affected in Pregnant Kidney Transplant Recipients

Pregnancy after renal transplantation is associated with an increased risk of complications. While a delicately balanced uterine immune system is essential for a successful pregnancy, little is known about the uterine immune environment of pregnant kidney transplant recipients. Moreover, children born to kidney transplant recipients are exposed in utero to immunosuppressive drugs, with possible consequences for neonatal outcomes. Here, we defined the effects of kidney transplantation on the immune cell composition during pregnancy with a cohort of kidney transplant recipients as well as healthy controls with uncomplicated pregnancies. Maternal immune cells from peripheral blood were collected during pregnancy as well as from decidua and cord blood obtained after delivery. Multiparameter flow cytometry was used to identify and characterize populations of cells. While systemic immune cell frequencies were altered in kidney transplant patients, immune cell dynamics over the course of pregnancy were largely similar to healthy women. In the decidua of women with a kidney transplant, we observed a decreased frequency of HLA-DR⁺ Treg, particularly in those treated with tacrolimus versus those that were treated with azathioprine next to tacrolimus, or with azathioprine alone. In addition, both the innate and adaptive neonatal immune system of children born to kidney transplant recipients was significantly altered compared to neonates born from uncomplicated pregnancies. Overall, our findings indicate a significant and distinct impact on the maternal systemic, uterine, and neonatal immune cell composition in pregnant kidney transplant recipients, which could have important consequences for the incidence of pregnancy complications, treatment decisions, and the offspring's health.

Planned Pregnancy in Kidney Transplantation. A Calculated Risk

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.

Twin pregnancy after kidney transplantation: case report and systematic review

BACKGROUND

Kidney transplantation is associated with fertility restoration in more than 50% of women with chronic kidney disease. Pregnancy after transplantation may affect women's health and fetal development, with higher rates of abortion, fetal growth restriction, and neonatal deaths. Twin pregnancy is a condition of high-risk for adverse maternal and perinatal outcomes, and its occurrence in women with previous kidney transplantation is rare.

CASE

32-year-old woman, recipient of living donor kidney transplantation, with a history of one pregnancy prior to transplantation, with current normal allograft function and no use of contraceptive method. At ten weeks of amenorrhea, ultrasound investigation showed a dichorionic diamniotic twin pregnancy. The following evaluation showed Chiari type II features in one fetus, and no detectable abnormality in the other one. There was appropriate blood pressure control with no need for an antihypertensive drug, and renal function remained normal without proteinuria. Calcium and a low dose of acetylsalicylic acid were used as preeclampsia prophylaxis. At 33 weeks of gestation, she presented premature rupture of membranes with spontaneous preterm labor. A cesarean section was performed due to the breech presentation of the first fetus. The patient persisted with normal graft function and without graft rejection during follow-up.

DISCUSSION AND CONCLUSION

Twin pregnancies after kidney transplantation are rare, and it is most frequently associated with preterm birth. We reported a successful twin pregnancy after kidney transplantation, with good perinatal and maternal outcomes, and without graft rejection or dysfunction.

Pregnancy outcomes in female patients exposed to cyclosporin-based versus tacrolimus-based immunosuppressive regimens after liver/kidney transplantation: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Pregnancy after transplantation is a challenge owing to the high risk of adverse maternal and foetal outcomes, and immunosuppressants may further impact these outcomes. There are no head-to-head randomized controlled trials comparing influences of cyclosporin and tacrolimus on pregnancy outcomes. Thus, we systematically reviewed and meta-analysed observational studies assessing the comparative influences of these two drugs on pregnancy outcomes in liver/kidney transplant recipients.

METHODS

Relevant studies comparing pregnancy outcomes with tacrolimus and cyclosporin head-to-head were searched in PubMed, EMBASE and Web of Science (from 1 January 2000 to 20 March 2020). The weighted mean difference and odds ratio (OR) were calculated to compare continuous and dichotomous variables, respectively, with 95% confidence intervals (CIs). Publication bias was estimated using funnel plots. The study quality was assessed according to the modified Newcastle-Ottawa scale.

RESULTS AND DISCUSSION

Overall, 10 observational studies of low quality, including a total of 1080 post-liver or kidney transplant pregnancies, were identified. Tacrolimus-treated recipients experienced a lower risk of gestational hypertension (28.0%; OR: 1.74; 95% CI: 1.27-2.39; p < 0.01). Cyclosporin-treated recipients showed a lower incidence of caesarean section (40.3%; OR: 0.62; 95% CI: 0.46-0.82; p < 0.01). Additionally, cyclosporin performed better in terms of the live birth rate (78.0%; OR: 1.38; 95% CI: 1.02-1.88; p = 0.04). No significant differences in the incidences of pre-eclampsia, gestational diabetes, preterm delivery and birth weight were observed.

WHAT IS NEW AND CONCLUSION

Tacrolimus performed better in patients with gestational hypertension, while cyclosporin was associated with a lower incidence of caesarean section and a higher incidence of live birth. The findings are based on relatively low-quality evidence, but may provide a reference for clinicians in their clinical monitoring and obstetric care for post-transplant pregnancies.

Fertility and Pregnancy in End Stage Kidney Failure Patients and after Renal Transplantation: An Update

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.

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

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

Evaluation of obstetric outcomes and prognostic significance of graft function in kidney transplant recipient pregnancies

Objective: To evaluate obstetric and kidney outcomes in pregnancies with kidney transplantation.Methods: We retrospectively reviewed 32 singleton pregnancies in kidney transplant recipients. Obstetric outcomes were explored according to the estimated glomerular filtration rates (eGFR) of patients.Results: The incidences of fetal growth restriction, preeclampsia were 18.8% and 34.4%, respectively. There was a significant negative correlation between first-trimester eGFR and perinatal mortality (r = -0.546, p = .0.001) and composite adverse obstetric outcome (r = -0.415, p = .0.018).Conclusion: The degree of transplanted kidney function impairment at the beginning of pregnancy is the major determinant of pregnancy outcome.

Pregnancy following kidney transplantation - impact on mother and graft function and focus on childrens' longitudinal development

BACKGROUND

Pregnancy after kidney transplantation has been considered as high risk for maternal and fetal complications. After careful patient selection successful pregnancies are described. Little is known about fetal outcomes and data is particularly scarce on childrens´ early development up to two years when born to kidney/-pancreas transplant recipients. Here, we analyzed maternal and fetal risk and evaluated graft function during pregnancy in transplanted women. We aimed to identify factors affecting the outcomes of mothers and their grafts during pregnancy and of children up to 2 years after delivery/ birth.

METHODS

All consecutive pregnancies in kidney/ kidney-pancreas recipients with live-born children from 2002 to 2016 were evaluated in two transplant centers (Charité Berlin/ University Tuebingen). All data was gathered from medical records. Impact of pregnancy on obstetrical risks, graft function and fetal development was evaluated. Additionally, for the first time development of children, including physical examination and assessment of neurological function were evaluated at 12 and 24 months.

RESULTS

Thirty-two pregnancies in 28 patients with a median duration of 34 gestational weeks (range, 24-38) were analyzed. 13 patients (46.4%) developed deterioration of kidney graft function > 10 ml/min during pregnancy. In majority, caesarean section was performed (75%). Twenty-five (78.1%) children were born prematurely, thereof (16%) < 28 weeks. Almost 70% had low birth weights (LBW) (< 2.500 g); median birth weight was 2.030 g. General health and physical constitution of children were unremarkable with normal development in 94% at 12 and 24 months of corrected age, respectively.

CONCLUSION

Despite the high rate of preterm birth and LBW, development up to two years was age-appropriate in this cohort. Due to low absolute numbers, increasing efforts in centralized counseling, diagnostics and committed specialist support are required. Decisive treatment of these high-risk patients in specialized units leading to better performance of these patients (mother/ fetus) is deemed superior. In order to confirm this, prospective studies on neonatal and pediatric outcomes with a standard-of-care comparator arm will be conducted.

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.

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.

Preeclampsia Risks in Kidney Donors and Recipients

PURPOSE OF REVIEW

To review the studies and practice guidelines on the preeclampsia risks in kidney donors and recipients.

RECENT FINDINGS

There is a small increased risk of gestational hypertension and preeclampsia in pregnancies that follow kidney donation. Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline (2017) and the 2015 American Society of Transplantation (AST) consensus conference statement recommends counseling kidney donors about this increased risk. There is no observed increase in fetal complications or eclampsia post-kidney donation. Preeclampsia is more commonly observed in kidney transplant recipients than the general population and these patients should be co-managed with an obstetrician with experience in managing high risk pregnancies. Although preeclampsia has not been found to have a deleterious effect on renal graft function, it can cause premature delivery. Risk calculators have been proposed and an elevated pre-pregnancy creatinine seems to be an important risk. KDIGO Clinical Practice Guidelines (2009) recommends attempting pregnancy when kidney function is stable with proteinuria of less than 1 g per day. The use of novel biomarkers for preeclampsia has not been published in this population. Preeclampsia is an important concern for female kidney donors and recipients of child-bearing age. These individuals should be appropriately counseled.

Outcome of pregnancy after renal transplantation

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Uterus transplantation: From animal models through the first heart beating pregnancy to the first human live birth

Absolute uterine factor infertility affects 3-5% of the general population, and unfortunately this condition is untreatable. There are some available options, including surrogacy or adoption, but neither of these suits each and every woman who desires to have her own genetic child. With recent advances in surgery and transplant immunology, uterus transplantation may be a source of hope for these women with uterine infertility. In the last decade, a number of animal species including rats, mice, rabbits, pigs, sheep, and primates have been used as experimental models, and pregnancies were achieved in some of these. Human data consist of 11 subjects yielding positive pregnancy results with no live births in the second trial from Turkey and, more fortunately, live births from the latest trial from Sweden. In the light of all these studies, uterus transplantation has been proven to be a viable option for women with uterine factor infertility.

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.

Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby

Parenthood is a central focus for women with chronic kidney disease, but raises important fears and uncertainties about risks to their own and their baby’s health. Pregnancy in women with background kidney disease, women receiving dialysis, or those with a functioning kidney transplant poses a challenging clinical scenario, associated with high maternal–fetal morbidity and potential impact on maternal renal health. Improvements in care over recent decades have led to a paradigm shift with cautious optimism and growing interest regarding pregnancies in women with chronic kidney disease. In this review, we discuss obstetric and renal outcomes, and practical aspects of management of pregnancy in this complex cohort.