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Han J, McCormick CA, Krelle A, Champion de Crespigny P, Unterscheider J. Pregnancy outcomes post-kidney transplantation across 23 years. Aust N Z J Obstet Gynaecol 2024; 64:269-276. [PMID: 38189187 DOI: 10.1111/ajo.13786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Pregnancy in kidney transplant recipients has become increasingly common. However, pregnancy carries higher risks to these patients compared to the general population. AIMS To describe pregnancy outcomes in kidney transplant recipients. MATERIALS AND METHODS We conducted a single-centre retrospective cohort study of kidney transplant recipients who delivered after 20 weeks gestation at a quaternary hospital in Victoria, Australia, between 2000 and 2022 inclusive. RESULTS The study included 37 pregnancies from 27 patients, accounting for 38 infants. Over half of recorded pregnancies occurred in the past five years (56.8%, n = 21). There were high rates of pre-existing hypertension (75.7%, n = 28). Pregnancy-induced hypertension and pre-eclampsia were common antenatal complications (21.6%, n = 8 and 48.6%, n = 18 respectively). Soluble fms-like tyrosine kinase-1 / placental growth factor ratios were elevated in all patients who developed severe pre-eclampsia (16.2%, n = 6). The median gestational age at birth was 36.4 weeks (range 20-40.4, Q1 32.9, Q3 37.6) and 59.5% (n = 22) of births were preterm. Unplanned caesarean without labour was the most common mode of birth (35.1%, n = 13). The overall caesarean rate was 62.1% (n = 23). Post-partum haemorrhage complicated over half of pregnancies (56.8%, n = 21). Fifty percent (n = 19) of infants were admitted for neonatal care, in particular neonatal intensive care, and had low birthweights under 2500 g. While there was a transient deterioration in kidney function, there was no graft rejection within one year of birth. CONCLUSIONS Clinicians should consider the high rates of pre-existing hypertension, preterm birth, and caesarean birth when counselling and managing pregnant kidney transplant recipients.
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Affiliation(s)
- Jessica Han
- Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Ciara Anne McCormick
- Department of Maternal Fetal Medicine, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Anna Krelle
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Paul Champion de Crespigny
- Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Julia Unterscheider
- Department of Maternal Fetal Medicine, Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
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Reitz A, Rouzaire M, Cahierc R, Pereira B, Lemal R, Garrouste C, Gallot D. [Obstetrical outcome of renal transplant patients followed in a type III maternity hospital. Retrospective study from 2000 to 2020]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:391-397. [PMID: 38296107 DOI: 10.1016/j.gofs.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 01/18/2024] [Accepted: 01/21/2024] [Indexed: 02/16/2024]
Abstract
AIM To describe pregnancy outcome of kidney transplant patients till 1 year postpartum. METHODS This retrospective, monocentric study included 15 kidney transplant patients who presented 18 pregnancies, between January 2000 and January 2020. For each of them, we searched for possible obstetrical, fetal and renal complications and we evaluated renal function before, during and after pregnancy. RESULTS The live birth rate was 84% (16/19) with an average gestational age at delivery of 37 weeks of gestation. The rate of prematurity was 50% (8/16), gestational diabetes was 16.6% (3/18) and preeclampsia was 27.7% (5/18). Cesarean section was performed in 61.1% (11/18) of cases including, 81.8% (9/11) unplanned surgery. The average birth weight was 2635 grams and 37.5% (6/16) of the newborn were small for gestational age. All patients had stable renal function before conception of pregnancy. We noticed two acute graft rejection during pregnancy with only one resulting in graft loss. Four patients had a reduced graft function in 12months of the postpartum. CONCLUSION Risk of maternal, fetal and renal complications remained high in kidney transplant recipients. Pregnancy should be carefully planned in transplanted women associated with adequate follow-up according to clinical guidelines (normal renal function and blood pressure without proteinuria before pregnancy, no recent graft rejection, period of one year after transplant respected and no teratogenic treatment in the month before pregnancy).
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Affiliation(s)
- Aurélie Reitz
- Service d'obstétrique, CHU de Clermont-Ferrand - Site Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - Marion Rouzaire
- CIC 1405 unité CRECHE, Inserm, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - Romain Cahierc
- Service d'obstétrique, CHU de Clermont-Ferrand - Site Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France
| | - Bruno Pereira
- Unité de biostatistiques, DRCI, CHU de Clermont-Ferrand, 58, rue Montalembert, 63000 Clermont-Ferrand cedex, France
| | - Richard Lemal
- Service d'hématologie clinique, CHU de Clermont-Ferrand - Site Gabriel-Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand cedex 1, France
| | - Cyril Garrouste
- Service de néphrologie, CHU de Clermont-Ferrand - Site Gabriel-Montpied, 58, rue Montalembert, 63000 Clermont-Ferrand cedex 1, France
| | - Denis Gallot
- Service d'obstétrique, CHU de Clermont-Ferrand - Site Estaing, 1, place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1, France; CIC 1405 unité CRECHE, Inserm, CHU Clermont-Ferrand, 63000 Clermont-Ferrand, France; CNRS UMR 6293, Inserm U1103, GReD, université Clermont Auvergne, 63000 Clermont-Ferrand, France.
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Suzuki T, Sugiura T, Okazaki J, Kimura H. Postpartum hemorrhage with associated placenta previa in a kidney transplant recipient: A case report. Int J Surg Case Rep 2024; 114:109109. [PMID: 38086133 PMCID: PMC10726234 DOI: 10.1016/j.ijscr.2023.109109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/22/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION The efficacy and safety of uterine artery embolization (UAE) and prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA) against postpartum hemorrhage (PPH) in pregnant women after kidney transplantation have not been reported. Here, we describe a case of PPH associated with placenta previa in pregnancy following kidney transplantation, which was managed with UAE and prophylactic REBOA. CASE PRESENTATION A 35-year-old, gravida 2, para 1 woman with total placenta previa presented with vaginal bleeding (460 mL) at 33 weeks and 3 days of gestation. Previously, she underwent a living-donor kidney transplantation for IgA nephropathy, and the renal artery of the transplanted kidney was anastomosed with the right internal iliac artery. An emergency cesarean section with prophylactic REBOA was performed under general anesthesia. A balloon catheter was introduced via the left femoral artery and positioned above the aortic bifurcation (Aortic zone 3). Upon confirming fetal delivery, the balloon was immediately inflated, and the total aortic occlusion time was 20 min. However, following aortic balloon deflation, atonic bleeding continued despite Bakri balloon usage and uterotonic drug administration. Subsequently, UAE was performed for the refractory PPH, the left uterine artery was embolized using a gelatin sponge, and hemostasis was successfully achieved. The patient recovered uneventfully and was discharged on postoperative day 7. DISCUSSION AND CONCLUSION In pregnancies following kidney transplantation, prophylactic REBOA controls bleeding; however, it decreases blood flow to the transplanted kidney. Furthermore, uterine nutrient vasculature alterations are observed, necessitating a thorough understanding of the uterine artery supply pathways during UAE.
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Affiliation(s)
- Toshinao Suzuki
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan.
| | - Takahiro Sugiura
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan.
| | - Junko Okazaki
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan
| | - Hiroaki Kimura
- Department of Obstetrics and Gynecology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan
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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.
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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
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Viki M, Jesudason S, Khong TY. Placental histopathology and correlated clinical outcomes in kidney transplant recipients. Pathology 2023; 55:974-978. [PMID: 37659910 DOI: 10.1016/j.pathol.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 04/10/2023] [Accepted: 06/06/2023] [Indexed: 09/04/2023]
Abstract
Pregnancies after kidney transplantation are high-risk. Whilst previous studies have explored pregnancy outcomes, there are no existing data on the placental histopathology findings of kidney transplant recipients and how these correlate with clinical outcomes. From 1976 to 2020, 62 pregnancies to 37 transplant recipients were identified in a South Australian clinical unit. The medical records were evaluated to identify if placental tissue had been sent for histopathology. The histology was reviewed contemporaneously, blinded to outcomes, following the Amsterdam consensus. The findings were correlated with the clinical data. Placental tissue was referred for histopathological examination in 20 pregnancies to 15 women. A high rate of adverse perinatal outcomes was noted, with fetal growth restriction (FGR; n=6), pre-eclampsia (n=8), worsening renal function with >10% increase in serum creatinine from preconception (n=9), pre-term birth (n=15), and antenatal hypertension (n=12). Maternal vascular malperfusion was seen in 14/20 pregnancies, including in all cases with pre-eclampsia, and was commonly observed with FGR (5/6 cases), decline in kidney function (8/9), antenatal hypertension (7/12) and preterm birth (12/15). In this high-risk population, increased obstetric ultrasound scans with uterine and umbilical Doppler should be considered to monitor and manage maternal uteroplacental vascular perfusion. We recommend all placental tissue from transplant recipients be referred for histopathological examination.
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Affiliation(s)
- Mthulisi Viki
- Department of Anatomical Pathology, SA Pathology at The Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health and Medical Science, The University of Adelaide, Adelaide, SA, Australia.
| | - Shilpanjali Jesudason
- Faculty of Health and Medical Science, The University of Adelaide, Adelaide, SA, Australia; Central Northern Adelaide Renal and Transplantation Service, The Royal Adelaide Hospital, Adelaide, SA, Australia
| | - T Yee Khong
- Faculty of Health and Medical Science, The University of Adelaide, Adelaide, SA, Australia; Department of Anatomical Pathology, SA Pathology at The Women's and Children's Hospital, Adelaide, SA, Australia
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Harding CC, Ephraim PL, Davenport CA, McElroy LM, Mohottige D, DePasquale N, Lunyera J, Strigo TS, Pounds IA, Riley J, Alkon A, Ellis M, Boulware LE. Association of Age and Gender With Concerns About Live Donor Kidney Transplantation Among Black Individuals. Transplant Proc 2023; 55:2403-2409. [PMID: 37945446 PMCID: PMC10872540 DOI: 10.1016/j.transproceed.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 10/04/2023] [Indexed: 11/12/2023]
Abstract
Black individuals are less likely to receive live donor kidney transplantation (LDKT) compared to others. This may be partly related to their concerns about LDKT, which can vary based on age and gender. We conducted a cross-sectional, secondary analysis of the baseline enrollment data from the Talking about Living Kidney Donation Support trial, which studied the effectiveness of social workers and financial interventions on activation towards LDKT among 300 Black individuals from a deceased donor waiting list. We assessed concerns regarding the LDKT process, including their potential need for postoperative social support, future reproductive potential, recipient and donor money matters, recipient and donor safety, and interpersonal concerns. Answers ranged from 0 ("not at all concerned") to 10 ("extremely concerned"). We described and compared participants' concerns both overall and stratified by age (≥45 years old vs <45 years old) and self-reported gender ("male" versus "female"). The participants' top concerns were donor safety (median [IQR] score 10 [5-10]), recipient safety (5 [0-10]), money matters (5 [0-9]), and guilt/indebtedness (5 [0-9]). Younger females had statistically significantly higher odds of being concerned about future reproductive potential (odds ratio [OR] 3.77, 95% CI 2.77, 4.77), and older males had statistically higher mean concern about postoperative social support (OR 1.79, 95% CI 0.19, 3.38). Interventions to improve rates of LDKT among Black individuals should include education and counseling about the safety of LDKT for both recipients and donors, reproductive counseling for female LDKT candidates of childbearing age, and addressing older males' needs for increased social support.
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Affiliation(s)
- Ceshae C Harding
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Patti L Ephraim
- Institute of Health System Science, Feinstein Institute for Medical Research, Northwell Health, New York, New York
| | - Clemontina A Davenport
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Lisa M McElroy
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Dinushika Mohottige
- Institute for Health Equity Research, Department of Population Health, Icahn School of Medicine at Mount Sinai, New York, New York; Barbara T. Murphy Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Nicole DePasquale
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Joseph Lunyera
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Tara S Strigo
- Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Iris A Pounds
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Jennie Riley
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Aviel Alkon
- General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Matthew Ellis
- Division of Nephrology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - L Ebony Boulware
- Wake Forest University School of Medicine, Winston-Salem, North Carolina.
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Al Sayyab M, Josephson MA. Double Jeopardy: The Complicated Interplay of Preeclampsia Risks to Mom, Baby, and Allograft in Kidney Transplant Recipients. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00166. [PMID: 37294696 PMCID: PMC10356116 DOI: 10.2215/cjn.0000000000000210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Mina Al Sayyab
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, Illinois
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8
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Habli M, Belal D, Sharma A, Halawa A. Infertility, pregnancy and breastfeeding in kidney transplantation recipients: Key issues. World J Meta-Anal 2023; 11:55-67. [DOI: 10.13105/wjma.v11.i3.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/22/2023] [Accepted: 02/13/2023] [Indexed: 03/01/2023] Open
Abstract
Chronic kidney disease (CKD), especially in advanced stages, is an important cause of infertility. In CKD patients, infertility has been linked to multiple factors. The pathophysiology of infertility related to CKD is complex and forked. Correction of modifiable factors can improve fertility in both genders. In males as well as females, successful kidney transplantation offers good chances of restoration of reproductive function. In female renal allograft recipients, recovery of reproductive functions in the post-transplant period will manifest as restoration of normal menses and ovulation. Owing to this improvement, there is a significant risk of unplanned pregnancy, hence the need to discuss methods of contraception before transplantation. In kidney transplant recipients, different contraceptive options for pregnancy planning, have been used. The selection of one contraception over another is based on preference and tolerability. Pregnancy, in renal transplanted females, is associated with physiologic changes that occur in pregnant women with native kidneys. Immunosuppressive medications during pregnancy, in a recipient with a single functioning kidney, expose the mother and fetus to unwanted complications. Some immunosuppressive drugs are contraindicated during pregnancy. Immunosuppressive medications should be discussed with renal transplant recipients who are planning to breastfeed their babies. In addition to antirejection drugs, other medications should be managed accordingly, whenever pregnancy is planned.
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Affiliation(s)
- Mohamad Habli
- Department of Internal Medicine, Division of Nephrology, Kingdom Hospital, Riyadh 11564, Saudi Arabia
| | - Dawlat Belal
- Kasr El-Ainy School of Medicine, Cairo University, Cairo 11562, Egypt
| | - Ajay Sharma
- Royal Liverpool University Hospital, Royal Liverpool University Hospital, Liverpool L7 8YE, United Kingdom
| | - Ahmed Halawa
- Department of Transplantation, Sheffield Teaching Hospitals, Sheffield S10 2JF, United Kingdom
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Wilson NK, Schulz P, Wall A, Parrott M, Testa G, Johannesson L, Sam T. Immunosuppression in Uterus Transplantation: Experience From the Dallas Uterus Transplant Study. Transplantation 2023; 107:729-736. [PMID: 36445981 DOI: 10.1097/tp.0000000000004437] [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] [Indexed: 12/02/2022]
Abstract
BACKGROUND Uterus transplantation is a temporary transplant allowing women with absolute uterine factor infertility to experience pregnancy and childbirth. The degree of immunosuppression (IS) required to prevent rejection while minimizing toxicity to the recipient and fetus remains an area of investigation. METHODS In this article, we describe immunosuppressive therapy, rejection episodes, infections, and adverse events in 14 uterus transplant recipients. Induction consisted of antithymocyte globulin and methylprednisolone. Ten recipients (71%) received no steroids postoperatively, and 4 (29%) had steroids tapered off at 42 d. All received oral tacrolimus, either immediate release (n = 2, 14%) or extended release (n = 12, 86%). Mycophenolate was used in 4 cases (29%), de novo azathioprine in 9 (64%), and de novo everolimus in 1 (7%). RESULTS Sixteen clinically silent, treatment-responsive rejection episodes occurred in 10 recipients. Five recipients (36%) experienced acute kidney injury. In 3 recipients, IS was discontinued due to renal dysfunction. Eleven infection episodes were noted in 7 recipients. No babies had congenital abnormalities. CONCLUSIONS Our experience demonstrates that safe IS regimens can be used for uterus transplant recipients before and during pregnancy.
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Affiliation(s)
- Nicole K Wilson
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX
| | - Philipp Schulz
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Anji Wall
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Megan Parrott
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Giuliano Testa
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Liza Johannesson
- Department of Transplant, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, TX
| | - Teena Sam
- Department of Pharmacy, Baylor University Medical Center, Dallas, TX
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Oki R, Unagami K, Kakogawa J, Beppu H, Banno T, Yagisawa T, Kanzawa T, Hirai T, Omoto K, Kitajima K, Shirakawa H, Hoshino J, Takagi T, Ishida H. Pregnancy Complications and Impact on Kidney Allograft After Kidney Transplantation in IgA Nephropathy. Transpl Int 2023; 36:11220. [PMID: 37213487 PMCID: PMC10193387 DOI: 10.3389/ti.2023.11220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/21/2023] [Indexed: 05/23/2023]
Abstract
Pregnancy in kidney transplantation (KT) recipients has been challenging because of the high risk of maternal, fetal, and renal complications. Although patients with immunoglobulin A nephropathy (IgAN)-chronic kidney disease (CKD) are at a high risk for hypertension in pregnancy (HIP), the maternal risk in KT recipients with IgAN as the etiology remains unclear. We retrospectively reviewed the medical records of pregnant KT recipients who delivered at our hospital. The incidence of maternal and fetal complications and the impact on kidney allografts between the group with IgAN as the primary kidney disease and the group with other primary diseases were compared. The analysis included 73 pregnancies in 64 KT recipients. The IgAN group had a higher incidence of HIP than the non-IgAN group (69% vs. 40%, p = 0.02). IgAN as primary kidney disease and interval from transplantation to conception were associated with HIP (OR 3.33 [1.11-9.92], p = 0.03, OR 0.83 [0.72-0.96], p < 0.01, respectively). The 20-year graft survival or prevention of CKD stage 5 in group with IgAN was lower than that in the group with other primary disease (p < 0.01). KT recipients should be informed of the risk of HIP and possibility of long-term worsening of postpartum renal function.
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Affiliation(s)
- Rikako Oki
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Nephrology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Kohei Unagami
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Nephrology, Tokyo Women’s Medical University, Shinjuku, Japan
- *Correspondence: Kohei Unagami,
| | - Jun Kakogawa
- Department of Obstetrics and Gynecology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Hiroko Beppu
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Nephrology, Ohkubo Hospital, Tokyo, Japan
| | - Taro Banno
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Takafumi Yagisawa
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Taichi Kanzawa
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Toshihito Hirai
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Kazuya Omoto
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Kumiko Kitajima
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Hiroki Shirakawa
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
- Department of Urology, Ohkubo Hospital, Tokyo, Japan
| | - Junichi Hoshino
- Department of Nephrology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Toshio Takagi
- Department of Urology, Tokyo Women’s Medical University, Shinjuku, Japan
| | - Hideki Ishida
- Department of Organ Transplant Medicine, Tokyo Women’s Medical University, Shinjuku, Japan
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Murata M, Tasaki M, Ikeda M, Saito K, Tomita Y. [PREGNANCIES IN KIDNEY TRANSPLANT RECIPIENTS, AN ANALYSIS OF 9 CASES]. Nihon Hinyokika Gakkai Zasshi 2023; 114:8-15. [PMID: 38246625 DOI: 10.5980/jpnjurol.114.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
(Objective) Pregnancy in kidney transplant recipient continues to remain challenging due to a high rate of cesarean section along with preterm delivery, and concern for worsening renal function. This study examined the prognosis and perinatal management of post-transplant pregnancies. (Patients and methods) A total of nine post-transplant recipients at Niigata University Medical and Dental Hospital between 2007 and 2021 were retrospectively examined. (Results) All pregnancies were planned. Calcineurin inhibitors and steroids were continued, and antimetabolites were changed to azathioprine. The mean age at delivery was 33±3.8 years, and the mean time from renal transplantation to delivery was 6.5±3.5 years. Five patients (55.5%) had cesarean sections, while four (44.5%) patients had normal vaginal deliveries. The mean gestational age was 35±3.0 weeks, and the mean birth weight was 2,336±565.4 g. No congenital malformation was observed. The most common reason for early delivery was worsening renal function, seen in six (66.7%) patients. The mean serum creatinine level before pregnancy was 1.11±0.23 mg/dL and then worsened to 1.59±0.37 mg/dL during pregnancy. However, it recovered to 1.14±0.40 mg/dL after delivery. One patient had antibody-mediated rejection with donor specific antibody (DSA) prior to pregnancy, and her renal graft function worsened slightly after delivery. Another patient had a de novo DSA after delivery, which was not detected before pregnancy. (Conclusions) In our hospital, pregnancy in kidney transplant recipients were safe and renal graft function after delivery was relatively stable. Patients may require adjustment of calcineurin inhibitors during pregnancy, and the appearance of DSA after delivery should be noted.
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Affiliation(s)
- Masaki Murata
- Departments of Urology and Molecular Oncology, Graduate School of Medical and Dental Sciences, Niigata University
| | - Masayuki Tasaki
- Departments of Urology and Molecular Oncology, Graduate School of Medical and Dental Sciences, Niigata University
| | - Masahiro Ikeda
- Departments of Urology and Molecular Oncology, Graduate School of Medical and Dental Sciences, Niigata University
| | - Kazuhide Saito
- Departments of Urology and Molecular Oncology, Graduate School of Medical and Dental Sciences, Niigata University
| | - Yoshihiko Tomita
- Departments of Urology and Molecular Oncology, Graduate School of Medical and Dental Sciences, Niigata University
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12
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Gumber R, Shah S. Reproductive Health in Women with Kidney Disease. Clin J Am Soc Nephrol 2022; 17:1716-1718. [PMID: 36418039 PMCID: PMC9718017 DOI: 10.2215/cjn.12461022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Ramnika Gumber
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Silvi Shah
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio
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13
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Barros T, Braga J, Correia A, Correia S, Martins LS, Braga A. Pregnancy in kidney transplantation women: perinatal outcomes and impact on kidney function. J Matern Fetal Neonatal Med 2022; 35:10355-10361. [PMID: 36216351 DOI: 10.1080/14767058.2022.2128650] [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: 01/20/2023]
Abstract
OBJECTIVES This study aimed to evaluate maternal and perinatal outcomes in pregnancies after kidney transplant (KT) and the impact of pregnancy on graft function. METHODS A descriptive and retrospective case-control study included 43 pregnancies in women after KT, followed in our institution, from January 1991 to December 2019. The control group included 200 non-transplanted pregnant women. Statistical analysis used SPSS 25.0 (SPSS Inc., Chicago, IL), and a p value of .05 was considered statistically significant. RESULTS We studied 43 pregnancies in 37 KT women. The live birth rate of KT pregnant was 81.4%. The mean interval between transplantation and pregnancy was 4.6 years (range 1-16). We found a higher rate of obstetric complications in pregnancies after KT: miscarriage (14.0%, OR 6.7 (2.0-22.1), p < .001), preeclampsia (31.4%, OR 25.7 (7.7-85.3), p < .001), and fetal growth restriction (37.1%, OR 37.6 (9.9-142.3), p < .001). The rate of urogenital infections and anemia during pregnancy was higher in the KT group (p < .001). The gestational age at delivery was 35.0 ± 2.8 weeks and premature delivery was observed in 24 (68.6%) cases. The cesarean rate was higher in the KT group (p < .001). In the KT group, there were two neonatal deaths due to prematurity complications. Renal function deterioration, measured by serum creatinine levels, was observed in two pregnancies. Immunosuppressive therapy was used in all pregnancies after KT, and dosage escalation of immunosuppressive therapy was necessary for 69.8%. CONCLUSIONS A higher rate of adverse obstetric outcomes was found in KT pregnant. Kidney function remained stable in most pregnancies. An antenatal and postpartum multidisciplinary approach is essential to improve outcomes and minimization of complications.
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Affiliation(s)
- Tânia Barros
- Maternal-Fetal Unit, Obstetrics Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - Jorge Braga
- Maternal-Fetal Unit, Obstetrics Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - Ana Correia
- Instituto de Ciências Biomédicas Abel Salazar, University do Porto, Oporto, Portugal
| | - Sofia Correia
- Nephrology Derpartment, Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - La Salete Martins
- Nephrology Derpartment, Centro Hospitalar Universitário do Porto, Oporto, Portugal
| | - António Braga
- Maternal-Fetal Unit, Obstetrics Department, Centro Materno Infantil do Norte, Centro Hospitalar Universitário do Porto, Oporto, Portugal
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14
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Outcomes of Children with Fetal and Lactation Immunosuppression Exposure Born to Female Transplant Recipients. Paediatr Drugs 2022; 24:483-497. [PMID: 35870080 DOI: 10.1007/s40272-022-00525-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 10/16/2022]
Abstract
Solid organ transplantation (SOT) is a lifesaving procedure for those with end-stage kidney, liver, heart, lung, and intestinal diseases, including females of childbearing age who wish to proceed with pregnancy following transplantation. While there is clear risk associated with use of mycophenolate during pregnancy, the risks associated with use of other immunosuppressant agents are less well understood, and the timing of use in pregnancy may be pertinent when considering the risk versus benefit for individual patients. In addition to overall fetal outcomes, including gestational age, birth weight, and mortality, this review summarizes published literature on additional complications that have been examined in association with maternal use during pregnancy and postpartum while breastfeeding. Compared with non-transplant pregnancies, pregnancies in transplant recipients are associated with lower birth weight and earlier gestational age. Effects associated with particular immunosuppressant agents in the infant include renal dysfunction from calcineurin inhibitors, myelosuppression from azathioprine, and decreased circulating immune cells with several agents. However, these effects are noted to primarily be transient, though the decrease in immune cells may predispose the infant to increased infectious complications in the first year of life. Utilizing relative infant dose estimations, nearly all commonly utilized immunosuppressants are likely safe during breastfeeding given the limited exposure to the infant.
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15
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Schulz P, Testa G, York JR, Johannesson L. Children after Uterus Transplantation: 2‐Year Outcomes from the Dallas UtErus Transplant Study (DUETS). BJOG 2022; 129:2117-2124. [DOI: 10.1111/1471-0528.17270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Philipp Schulz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center Dallas
| | - Giuliano Testa
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center Dallas
| | - Jackie R. York
- Department of Neonatology Baylor University Medical Center Dallas
| | - Liza Johannesson
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center Dallas
- Department of Obstetrics and Gynecology Baylor University Medical Center Dallas
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16
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Shah S, Verma P. Pregnancy-Related Acute Kidney Injury: Do We Know What to Do? Nephron Clin Pract 2022; 147:35-38. [PMID: 35793648 PMCID: PMC9816347 DOI: 10.1159/000525492] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/06/2022] [Indexed: 01/11/2023] Open
Abstract
Pregnancy-related AKI is a global health problem and is associated with a higher risk of both maternal and fetal morbidity and mortality. Risk factors for developing AKI during pregnancy include older age, history of preeclampsia, and comorbidities like diabetes. Hyperemesis gravidarum is a common cause of AKI during the first trimester, and conditions such as preeclampsia, acute fatty liver disease of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, and placental abruption are important causes of AKI later in the pregnancy. Diagnosis of pregnancy-related AKI is challenging due to the lack of standard criteria and overlap of clinical manifestations among different etiologies. Timely diagnosis of pregnancy-related AKI is instrumental. Specific treatment includes steroids and immunosuppressive therapy for glomerulonephritis, prompt delivery for severe preeclampsia and acute fatty liver of pregnancy, plasmapheresis for thrombotic thrombocytopenic purpura, and eculizumab for the atypical hemolytic uremic syndrome. Due to the high complexity, management of pregnancy-related AKI should be performed by a multidisciplinary team consisting of a nephrologist, obstetrician, and neonatologist.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
| | - Prasoon Verma
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States
- Division of Neonatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United States
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17
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Lichtenberg S, Freilich Rom D, Aspitz HZ, Keshet R, Rahamimov R, Rozen-Zvi B. Second pregnancy following kidney transplantation is not associated with an increased risk of graft loss in a single center retrospective cohort study. Clin Transplant 2022; 36:e14741. [PMID: 35670647 DOI: 10.1111/ctr.14741] [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: 02/16/2022] [Revised: 04/22/2022] [Accepted: 05/26/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Previous studies on first pregnancy following kidney transplantation (KT) show no association with decreased graft survival. This study examined patients with multiple gestations compared to a single pregnancy following KT and evaluated the risk of graft function deterioration. METHODS A retrospective cohort study on fertile female kidney transplant recipients (KTRs) from Rabin Medical Center between January 2001 and December 2017 was performed. Data were collected on patients' comorbidities, pregnancy complications, graft loss, mortality, and lab results. Time-varying COX analysis was performed - second pregnancy being the time-related variable. RESULTS Fifty-two KTRs split into 30 single pregnancy and 22 multiple pregnancy patients following KT. Single pregnancy patients were older during their first pregnancy and had a higher caesarian section rate. During a median follow-up period of 5.6 years, multiple pregnancies, compared to a single pregnancy, were not associated with an increased rate of graft loss. No significant difference was seen between first and second pregnancy in gestational age, birth weight, graft function, and proteinuria rates. CONCLUSIONS Second pregnancy following KT was not shown to be associated with a decreased graft survival. In addition, obstetrical, maternal, and fetal complication rates are not increased in second compared to first pregnancy following KT.
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Affiliation(s)
- Shelly Lichtenberg
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Petah-Tikva, Israel
| | - Dana Freilich Rom
- Department of Family Medicine, Central District, Clalit Health Services, Israel
| | | | - Rom Keshet
- Bert W. Strassburger Lipid Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Ruth Rahamimov
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Benaya Rozen-Zvi
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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18
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Yadav A, Salas MAP, Coscia L, Basu A, Rossi AP, Sawinski D, Shah S. Acute kidney injury during pregnancy in kidney transplant recipients. Clin Transplant 2022; 36:e14668. [PMID: 35396888 PMCID: PMC9285565 DOI: 10.1111/ctr.14668] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/31/2022] [Accepted: 04/02/2022] [Indexed: 11/29/2022]
Abstract
Pregnancy-related acute kidney injury (AKI) is a public health problem and remains an important cause of maternal and fetal morbidity and mortality. The incidence of pregnancy-related AKI has increased in developed countries due to increase in maternal age and higher detection rates. Pregnancy in women with kidney transplants is associated with higher adverse outcomes like preeclampsia, preterm births, and allograft dysfunction, but limited data exist on causes and outcomes of pregnancy-related AKI in the kidney transplant population. Diagnosis of AKI during pregnancy remains challenging in kidney transplant recipients due to lack of diagnostic criteria. Management of pregnancy-related AKI in the kidney transplant population requires a multidisciplinary team consisting of transplant nephrologists, high-risk obstetricians, and neonatologists. In this review, we discuss pregnancy-related acute kidney injury in women with kidney transplants, etiologies, pregnancy outcomes, and management strategies. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anju Yadav
- Division of Nephrology, Department of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Maria Aurora Posadas Salas
- Division of Nephrology and Hypertension, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA
| | - Arpita Basu
- Division of Transplant and Division of Nephrology and Hypertension, Emory University, Atlanta, GA
| | | | - Deirdre Sawinski
- Division of Nephrology and Transplantation, Weill Cornell College of Medicine, New York, NY
| | - Silvi Shah
- Division of Nephrology, Department of Medicine, University of Cincinnati, Cincinnati, OH
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19
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Determinants of perinatal outcomes in dialysed and transplanted women in Australia. Kidney Int Rep 2022; 7:1318-1331. [PMID: 35685315 PMCID: PMC9171625 DOI: 10.1016/j.ekir.2022.03.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/11/2022] [Indexed: 12/17/2022] Open
Abstract
Introduction Drivers of adverse perinatal outcomes in pregnancies of women receiving chronic kidney replacement therapy (KRT) remain poorly understood. Methods Births ≥ 20 weeks of gestation in Australian women receiving KRT were analyzed for perinatal outcomes stratified by maternal KRT exposure (dialysis or transplant, analyzed separately), by linking the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and perinatal data sets (1991–2013). Results Of 2,948,084 babies (1,628,181 mothers), 248 were born to mothers receiving KRT (transplant, n = 211; dialysis, n = 37), with live birth rates ≥ 94%. The perinatal death rate was 162, 62, and 9 per 1000 births in the dialysis, transplant, and non-KRT cohorts, respectively. Babies exposed to KRT had increased odds of prematurity, small-for-gestational age (SGA), poor birth condition, resuscitation, intensive care admission, and longer hospitalization, with the dialysis cohort having worse outcomes. Preterm babies of dialyzed and transplanted mothers (compared with preterm babies with no KRT exposure) experienced 1.6- to 2.7-fold higher odds for all adverse outcomes, except birthweight < 2500 g, which was 11-fold higher for the dialysis cohort. In adjusted analyses, transplanted women with better allograft function (serum creatinine ≤ 120 μmol/l) still had >10-fold higher odds of preterm birth and low birthweight and 1.8- to 4.6-fold increased odds of other adverse outcomes. In transplanted women, mediation analysis revealed that pregnancy-induced hypertension contributed only a modest proportional effect (2.5%–11.2%) on adverse outcomes. Conclusion Maternal dialysis and transplantation conferred excess perinatal morbidity, particularly for preterm babies, and even in women with good preconception allograft function. Pregnancy-induced hypertension is not the predominant determinant of perinatal morbidity. Preconception counseling of women with kidney disease should encompass discussion of perinatal complications.
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20
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Mira FS, Oliveira J, Sousa F, Antunes D, Figueiredo AC, Borges A, Pais MSJ, Galvão A, Moura P, Alves R. Kidney graft function before pregnancy as a predictor of graft, maternal and fetal outcomes in pregnant renal transplant recipients. J Perinat Med 2022; 50:185-191. [PMID: 34727592 DOI: 10.1515/jpm-2021-0102] [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: 02/25/2021] [Accepted: 10/19/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Maternal and fetal complications can occur in pregnant kidney transplant recipients. Since these are high-risk pregnancies, they require a multidisciplinary follow-up to prematurely detect adverse events. Identifying factors that would affect fetal, maternal and graft outcomes is essential to further stratify the risk of pregnant kidney transplant recipients. METHODS All pregnancies in kidney transplant recipients followed in a single center for 30 years were included. Data included previous transplant information and blood and urine tests performed before pregnancy. Impact of graft function on fetal, maternal and graft outcomes was evaluated. RESULTS There were 41 pregnancies among 34 patients. Mean gestational age of 35 ± 3 weeks. Caesarean section was performed in 69.4% of patients. Five pregnancies were unsuccessful (12.2%). Four patients suffered an acute graft dysfunction (9.8%) and 12 (29.3%) had a serious maternal hypertensive disorder (preeclampsia, eclampsia or HELLP syndrome). Graft function before pregnancy showed significant correlation with adverse outcomes. CONCLUSIONS A proteinuria >669 mg/g, serum creatinine >1.75 mg/dL and glomerular filtration rate <36.2 mL/min/1.73 m2 before pregnancy were correlated to graft dysfunction during pregnancy. Similar values of proteinuria were also associated with a risk of maternal hypertensive disorders and pregnancy failure. Therefore, in patients with proteinuria and graft dysfunction, follow-up should be stricter to quickly detect complications.
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Affiliation(s)
- Filipe S Mira
- Nephrology Department, Coimbra University Hospital, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Joana Oliveira
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Obstetrics A Department, Coimbra University Hospital, Coimbra, Portugal
| | - Filipa Sousa
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Obstetrics A Department, Coimbra University Hospital, Coimbra, Portugal
| | - Dora Antunes
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Obstetrics A Department, Coimbra University Hospital, Coimbra, Portugal
| | - Ana Carolina Figueiredo
- Nephrology Department, Coimbra University Hospital, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Andreia Borges
- Nephrology Department, Coimbra University Hospital, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Maria S J Pais
- Obstetrics A Department, Coimbra University Hospital, Coimbra, Portugal
| | - Ana Galvão
- Nephrology Department, Coimbra University Hospital, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Paulo Moura
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,Obstetrics A Department, Coimbra University Hospital, Coimbra, Portugal
| | - Rui Alves
- Nephrology Department, Coimbra University Hospital, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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21
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Immunosuppressive Drugs. ENCYCLOPEDIA OF INFECTION AND IMMUNITY 2022. [PMCID: PMC8987166 DOI: 10.1016/b978-0-12-818731-9.00068-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Immunosuppressant is a class of medicines that inhibit or decrease the intensity of the immune response in the body. Most of these medications are used to allow the body less likely to resist a transplanted organ. In solid organ transplantation, immunosuppressive agents are needed for the activation of early-stage immunosuppression, the management of late-stage immunosuppression or for the maintenance of organ rejection. The emergence of novel agents and improvements in immunosuppression regimens after transplantation are significant factors leading to this progress. However, these drugs also increase the risk of infection, cancers and specific adverse side effects specific to each agent in patients particularly in pregnant women and fertility issues. Corona virus disease being hot topic of debate is has given positive outcome to immunosuppressive drugs however need more attention in future. Transplant centers across the world utilize multiple immunosuppression protocols; nevertheless, each patient can require an individually formulated immunosuppression regimen to manage the advantages and possible damage of treatment thus eliminating the likelihood of their primary disease recurrence.
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22
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Feyaerts D, Gillard J, van Cranenbroek B, Rigodanzo Marins L, Baghdady MMS, Comitini G, Lely AT, van Hamersvelt HW, van der Heijden OWH, Joosten I, van der Molen RG. Maternal, Decidual, and Neonatal Lymphocyte Composition Is Affected in Pregnant Kidney Transplant Recipients. Front Immunol 2021; 12:735564. [PMID: 34777345 PMCID: PMC8585145 DOI: 10.3389/fimmu.2021.735564] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Dorien Feyaerts
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Joshua Gillard
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Section Pediatric Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Bram van Cranenbroek
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lina Rigodanzo Marins
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Gynecology and Obstetrics, Hospital de Clinicas de Porto Alegre, Rio Grande do Sul, Brazil
| | - Mariam M S Baghdady
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Gaia Comitini
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - A Titia Lely
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht, Netherlands
| | | | | | - Irma Joosten
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Renate G van der Molen
- Radboud Institute for Molecular Life Sciences, Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud University Medical Center, Nijmegen, Netherlands
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23
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Shah S, Christianson AL, Bumb S, Verma P. Contraceptive use among women with kidney transplants in the United States. J Nephrol 2021; 35:629-638. [PMID: 34773601 PMCID: PMC8926989 DOI: 10.1007/s40620-021-01181-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/07/2021] [Indexed: 12/02/2022]
Abstract
Background Kidney transplant improves reproductive function in women with end-stage kidney disease. Little is known about contraceptive use in women with history of kidney transplants. Methods Using data from the United States Renal Data System, we evaluated for each calendar year women with kidney transplantation between 1/1/2005 and 12/31/2013 who were aged 15–44 years with Medicare as the primary payer and linked data from the United Network for Organ Sharing, for up to three entire years after the date of transplantation. We determined rates of contraceptive use and used multivariable logistic regression to identify factors associated with contraceptive use. Results The study cohort included 13,150 women and represented 26,624 person-years. The rate of contraceptive use was 9.5%. Compared to women aged 15–24 years, contraceptive use was lower in women aged 30–34 years (OR 0.67; CI 0.58–0.78), 35–39 years (OR 0.36; CI 0.31–0.43), and 40–44 years (OR 0.23; CI 0.19–0.28). Compared to white women, contraceptive use was higher both in black women (OR 1.26; CI 1.10–1.43) and Native American women (OR 1.52; CI 1.02–2.26). Women had lower rates of contraceptive use in the second-year post-transplant (OR 0.87; CI 0.79–0.94) and the third-year post-transplant (OR0.69; CI 0.62–0.76) than in the first-year post-transplant. Women with a history of diabetes had a lower likelihood of contraceptive use (OR 0.80; CI 0.65–0.99). Conclusion Among women with kidney transplants, contraceptive use remains low at 9.5%. Factors associated with a higher likelihood of contraceptive use include younger age and black and Native American race/ethnicity; and second- and third-year post-transplant. The history of diabetes is associated with a lower likelihood of contraceptive use. The study highlights the need of increasing awareness for safe and effective contraceptive use in women with kidney transplants. Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-01181-0.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology, Kidney C.A.R.E. (Clinical Advancement, Research and Education) Program, University of Cincinnati, 231 Albert Sabin Way, MSB 6112, Cincinnati, OH, 45267, USA.
| | | | - Shalini Bumb
- Division of Nephrology, Kidney C.A.R.E. (Clinical Advancement, Research and Education) Program, University of Cincinnati, 231 Albert Sabin Way, MSB 6112, Cincinnati, OH, 45267, USA
| | - Prasoon Verma
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Wall AE, Testa G, Axelrod D, Johannesson L. Uterus transplantation-questions and answers about the procedure that is expanding the field of solid organ transplantation. Proc AMIA Symp 2021; 34:581-585. [PMID: 34456477 DOI: 10.1080/08998280.2021.1925064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Uterus transplant is a new and rapidly evolving field of solid organ transplantation designed to help women with absolute uterine-factor infertility who desire to carry their own pregnancies. The advent of this procedure and human clinical trials of uterus transplantation have raised technical, clinical, and ethical questions. We address several questions about uterus transplantation based on available literature and the clinical experience at Baylor University Medical Center, which has the largest uterus transplant program in the United States.
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Affiliation(s)
- Anji E Wall
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - Giuliano Testa
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | - David Axelrod
- Division of Transplantation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Liza Johannesson
- Division of Abdominal Transplantation, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas.,Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas
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Usage of Tacrolimus and Mycophenolic Acid During Conception, Pregnancy, and Lactation, and Its Implications for Therapeutic Drug Monitoring: A Systematic Critical Review. Ther Drug Monit 2021; 42:518-531. [PMID: 32398419 DOI: 10.1097/ftd.0000000000000769] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Conception, pregnancy, and lactation following solid organ transplantation require appropriate management. The most frequently used immunosuppressive drug combination after solid organ transplantation consists of tacrolimus (Tac) plus mycophenolic acid (MPA). Here, the effects of Tac and MPA on fertility, pregnancy, and lactation are systematically reviewed, and their implications for therapeutic drug monitoring (TDM) are discussed. METHODS A systematic literature search was performed (August 19, 2019) using Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science, and 102 studies were included. Another 60 were included from the reference list of the published articles. RESULTS As MPA is teratogenic, women who are trying to conceive are strongly recommended to switch from MPA to azathioprine. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes. Nevertheless, in 2015, the drug label was updated with additional risk minimization measures in a pregnancy prevention program. Data on MPA pharmacokinetics during pregnancy and lactation are limited. Tac treatment during conception, pregnancy, and lactation seems to be safe in terms of the health of the mother, (unborn) child, and allograft. However, Tac may increase the risk of hypertension, preeclampsia, preterm birth, and low birth weight. Infants will ingest very small amounts of Tac via breast milk from mothers treated with Tac. However, no adverse outcomes have been reported in children exposed to Tac during lactation. During pregnancy, changes in Tac pharmacokinetics result in increased unbound to whole-blood Tac concentration ratio. To maintain Tac concentrations within the target range, increased Tac dose and intensified TDM may be required. However, it is unclear if dose adjustments during pregnancy are necessary, considering the higher concentration of (active) unbound Tac. CONCLUSIONS Tac treatment during conception, pregnancy and lactation seems to be relatively safe. Due to pharmacokinetic changes during pregnancy, a higher Tac dose might be indicated to maintain target concentrations. However, more evidence is needed to make recommendations on both Tac dose adjustments and alternative matrices than whole-blood for TDM of Tac during pregnancy. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes, whereas MPA use in women during conception and pregnancy is strongly discouraged.
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Irino K, Arinobu Y, Ayano M, Kawano S, Kimoto Y, Mitoma H, Akahoshi M, Akashi K, Horiuchi T, Niiro H. Predictive factors of fetal and maternal pregnancy outcomes in Japanese patients with systemic lupus erythematosus. Lupus 2021; 30:1637-1643. [PMID: 34266321 DOI: 10.1177/09612033211031989] [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: 11/16/2022]
Abstract
OBJECTIVE The number of pregnant and delivery cases in systemic lupus erythematosus (SLE) patients are increasing due to the advances in therapies. However, there are many problems such as the exacerbation of SLE during pregnancy and the risk of fetal complications. We investigated the impact of both pregnancy on lupus and lupus on pregnancy in Japanese patients. METHODS We retrospectively analyzed 64 pregnancies in 39 cases of lupus patients at Kyushu University Hospital, Japan, from October 2002 to July 2018 and then assessed the clinical profiles and maternal and fetal outcomes. RESULTS In terms of the impact of pregnancy on SLE, 29.7% of patients had lupus flare during pregnancy. Multivariate analysis showed that flare rates were significantly higher in patients who discontinued the immunosuppressants when pregnancy was detected or before pregnancy. Pregnancy results were 25.0% for preterm birth, 39.1% for low birth weight infants, and 31.3% for small-for-gestational-age infants. Regarding the effect of SLE on fetal death, the rates of stillbirth were significantly higher in cases whose C3 value at 12 weeks of gestation was lower than before conception. Preterm birth was associated with disease duration and lupus flare during pregnancy. CONCLUSIONS Discontinuation of immunosuppressive drugs was a predictive factor for lupus flare during pregnancy. Further, the decrease of C3 levels at 12 weeks of gestation from baseline was a predictive factor for fetal loss. It is essential for lupus pregnant patients to prevent flares, even with the use of immunosuppressive medications.
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Affiliation(s)
- Kensuke Irino
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yojiro Arinobu
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Shotaro Kawano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Yasutaka Kimoto
- Faculty of Medical Sciences Medical Education, Kyushu University, Fukuoka, Japan
| | - Hiroki Mitoma
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Mitsuteru Akahoshi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Takahiko Horiuchi
- Department of Internal Medicine, 73912Kyushu University Beppu Hospital, Kyushu University Beppu Hospital, Beppu, Japan
| | - Hiroaki Niiro
- Faculty of Medical Sciences Medical Education, Kyushu University, Fukuoka, Japan
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Chewcharat A, Kattah AG, Thongprayoon C, Cheungpasitporn W, Boonpheng B, Gonzalez Suarez ML, Craici IM, Garovic VD. Comparison of hospitalization outcomes for delivery and resource utilization between pregnant women with kidney transplants and chronic kidney disease in the United States. Nephrology (Carlton) 2021; 26:879-889. [PMID: 34240784 DOI: 10.1111/nep.13938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 06/30/2021] [Accepted: 07/04/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study aimed to assess outcomes of delivery hospitalizations, including acute kidney injury (AKI), obstetric and foetal events and resource utilization among pregnant women with kidney transplants compared with pregnant women with no known kidney disease and those with chronic kidney disease (CKD) Stages 3-5. METHOD Hospitalizations for delivery in the US were identified using the enhanced delivery identification method in the National Inpatient Sample dataset from the years 2009 to 2014. Diagnoses of CKD Stages 3-5, kidney transplantation, along with obstetric events, delivery methods and foetal events were identified using ICD-9-CM diagnosis and procedure codes. Patients with no known kidney disease group were identified by excluding any diagnoses of CKD, end stage kidney disease, and kidney transplant. Multivariable logistic regression accounting for the survey weights and matched regression was conducted to investigate the risk of maternal and foetal complications in women with kidney transplants, compared with women with no kidney transplants and no known kidney disease, and to women with CKD Stages 3-5. RESULT A total of 5, 408, 215 hospitalizations resulting in deliveries were identified from 2009 to 2014, including 405 women with CKD Stages 3-5, 295 women with functioning kidney transplants, and 5, 405, 499 women with no known kidney disease. Compared with pregnant women with no known kidney disease, pregnant kidney transplant recipients were at higher odds of hypertensive disorders of pregnancy (OR = 3.11, 95% CI [2.26, 4.28]), preeclampsia/eclampsia/HELLP syndrome (OR = 3.42, 95% CI [2.54, 4.60]), preterm delivery (OR = 2.46, 95% CI [1.75, 3.45]), foetal growth restriction (OR = 1.74, 95% CI [1.01, 3.00]) and AKI (OR = 10.46, 95% CI [5.33, 20.56]). There were no significant differences in rates of gestational diabetes or caesarean section. Pregnant women with kidney transplants had 1.30-times longer lengths of stay and 1.28-times higher costs of hospitalization. However, pregnant women with CKD Stages 3-5 were at higher odds of AKI (OR = 5.29, 95% CI [2.41, 11.59]), preeclampsia/eclampsia/HELLP syndrome (OR = 1.72, 95% CI [1.07, 2.76]) and foetal deaths (OR = 3.20, 95% CI [1.06, 10.24]), and had 1.28-times longer hospital stays and 1.37-times higher costs of hospitalization compared with pregnant women with kidney transplant. CONCLUSION Pregnant women with kidney transplant were more likely to experience adverse events during delivery and had longer lengths of stay and higher total charges when compared with women with no known kidney disease. However, pregnant women with moderate to severe CKD were more likely to experience serious complications than kidney transplant recipients.
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Affiliation(s)
- Api Chewcharat
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Andrea G Kattah
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Wisit Cheungpasitporn
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Boonphiphop Boonpheng
- Department of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Maria L Gonzalez Suarez
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Iasmina M Craici
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Akamine Y, Fujiyama N, Kagaya H, Saito M, Miura H, Terada Y, Takahashi T, Satoh S, Miura M. Tacrolimus concentrations after renal transplantation in a mother-neonate dyad: Maternal, neonatal and breast milk measurements. J Clin Pharm Ther 2021; 46:1800-1803. [PMID: 34041772 DOI: 10.1111/jcpt.13451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/26/2021] [Accepted: 05/11/2021] [Indexed: 12/15/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE We aim to add to the few reports on tacrolimus concentrations in breast milk and in maternal, umbilical vein and neonatal blood after maternal renal transplantation. CASE SUMMARY In a 30-year-old pregnant woman, the tacrolimus concentration at delivery was the same in maternal, umbilical vein and neonatal blood. The breast milk/maternal blood tacrolimus ratio ranged from 0.40 to 0.64. WHAT IS NEW AND CONCLUSION The maternal and neonatal blood tacrolimus concentrations at birth are equivalent; thus, one must assume that maternal tacrolimus concentrations directly affect the foetus and/or neonate. Tacrolimus is not detectable in the neonate 3 weeks after birth, suggesting that there is minimal transfer through breast milk.
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Affiliation(s)
- Yumiko Akamine
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Nobuhiro Fujiyama
- Center for Kidney Disease and Transplantation, Akita University Hospital, Akita, Japan
| | - Hideaki Kagaya
- Department of Pharmacy, Akita University Hospital, Akita, Japan
| | - Mitsuru Saito
- Department of Urology, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiroshi Miura
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yukihiro Terada
- Department of Obstetrics and Gynecology, Akita University Graduate School of Medicine, Akita, Japan
| | - Tsutomu Takahashi
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita, Japan
| | - Shigeru Satoh
- Center for Kidney Disease and Transplantation, Akita University Hospital, Akita, Japan
| | - Masatomo Miura
- Department of Pharmacy, Akita University Hospital, Akita, Japan
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Drug Exposure in Newborns: Effect of Selected Drugs Prescribed to Mothers During Pregnancy and Lactation. Ther Drug Monit 2021; 42:255-263. [PMID: 32068668 DOI: 10.1097/ftd.0000000000000747] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The number of newborns exposed to therapeutic drugs during pregnancy is growing because of the increased use of drugs during pregnancy. In recent years, advances in our understanding of drug placental transfer have augmented the likelihood of a healthy baby in mothers with chronic diseases needing drug therapy. Globally, for example, more than 1.4 million pregnancies in 2015 have been burdened with antiretroviral drugs due to an increasing number of HIV-positive women treated with these drugs, particularly in low- and middle-income countries. In most cases, the fetus is exposed to much higher drug doses in utero than the newborn nursed by the mother. Drug transfer through the placenta takes place by passive diffusion, active transport, or facilitated transport, and drug concentrations in the fetal circulation may be comparable to that in the mother's blood concentration. The excretion of drugs into breastmilk predominantly occurs by passive diffusion, allowing only the non-protein-bound fraction of the blood drug concentration to penetrate. Drug agencies in the United States and Europe highly recommend performing clinical trials in pregnant or breastfeeding women. However, only a few drugs have reported statistically sound data in these patient groups. Most available results concerning pregnancy are obtained from observational studies after birth, assessing outcomes in the newborn or by measuring drug concentrations in the mother and umbilical cord blood. In the case of the lactation period, some studies have evaluated drug concentrations in breastmilk and blood of the mother and/or infant. In this review, exposure to antiretrovirals, immunosuppressants used after solid organ transplantation, and antiepileptics during pregnancy and lactation has been discussed in detail.
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Boulay H, Mazaud-Guittot S, Supervielle J, Chemouny JM, Dardier V, Lacroix A, Dion L, Vigneau C. Maternal, foetal and child consequences of immunosuppressive drugs during pregnancy in women with organ transplant: a review. Clin Kidney J 2021; 14:1871-1878. [PMID: 34345409 PMCID: PMC8323135 DOI: 10.1093/ckj/sfab049] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 03/01/2021] [Indexed: 02/06/2023] Open
Abstract
Although pregnancy remains exceptional in women after heart, liver or lung transplant, obstetricians and nephrologists are regularly confronted with pregnancy in renal transplant recipients. National and international registries have described the epidemiology of maternal, foetal and neonatal complications, and transplantation societies have published recommendations on the monitoring of these high-risk pregnancies. In this review, we summarize the existing data on maternal and foetal complications of pregnancies in women after renal transplant, especially the management of immunosuppression. We also describe the few available data on the middle- and long-term outcomes of their children who were exposed in utero to immunosuppressive drugs.
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Affiliation(s)
- Hugoline Boulay
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Séverine Mazaud-Guittot
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Jeanne Supervielle
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Jonathan M Chemouny
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Virginie Dardier
- Laboratoire de psychologie, comportement, cognition et communication (LP3 C), Université Rennes-Rennes 2, Rennes, France
| | - Agnes Lacroix
- Laboratoire de psychologie, comportement, cognition et communication (LP3 C), Université Rennes-Rennes 2, Rennes, France
| | - Ludivine Dion
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
| | - Cécile Vigneau
- University of Rennes, CHU Rennes, INSERM, EHESP, IRSET (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000, Rennes, France
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Pregnancy in Liver Transplantation Recipients Is Associated With Increased Complications and Healthcare Utilization. Am J Gastroenterol 2021; 116:560-567. [PMID: 33470611 DOI: 10.14309/ajg.0000000000001135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/30/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Given the increased rates of pregnancy in liver transplant recipients, evaluating the safety of pregnancy is crucial. We aim to evaluate pregnancy-related complications and outcomes in liver transplant recipients. METHODS A retrospective nationwide review comparing pregnancy outcomes in liver transplant recipients vs the general population was performed between 2005 and 2013. Propensity-matched and multivariable regression analyses were performed to study pregnancy- and delivery-related complications in addition to patient and hospital outcomes. RESULTS A total of 38,449,030 pregnancy-related admissions were evaluated in this study including 1,469 (0.004%) admissions in liver transplant recipients. Liver transplant recipients were more likely to undergo a caesarean delivery (60% vs 36%) and have a pregnancy-related complication (56% vs 27%) including miscarriage, intrauterine growth restriction, portpartum hemorrhage, hypertension, preeclampsia, and thromboembolism (P < 0.001) compared with the general population. Propensity-weighted analysis revealed higher rates of pregnancy complications (odds ratio 2.11, 95% confidence interval [CI] 1.63-2.73), cost ($3,023, 95% CI $850-$5,197), and longer length of stay (1.52 days, 95% CI 0.62-2.41) in transplant recipients. Liver transplant recipients experienced zero inpatient mortalities compared with 0.01% of the general population. Transplant recipients with at least 1 complication had a longer length of stay (2.45 days, 95% CI 1.44-3.45) and higher cost of admission ($5,205, 95% CI $2,848-$7,561) compared with transplant recipients without a complication. DISCUSSION Pregnancy after liver transplant is associated with higher rates of complications and worse outcomes without an increased risk of mortality.
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Therapeutic strategy of pregnancy associated with renal transplant and SARS-CoV-2 infection – case report. GINECOLOGIA.RO 2021. [DOI: 10.26416/gine.33.3.2021.5307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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The Effects of Immunosuppressive Treatment during Pregnancy on the Levels of Potassium, Iron, Chromium, Zinc, Aluminum, Sodium and Molybdenum in Hard Tissues of Female Rats and Their Offspring. Int J Mol Sci 2020; 21:ijms21239038. [PMID: 33261165 PMCID: PMC7731177 DOI: 10.3390/ijms21239038] [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: 10/14/2020] [Revised: 11/14/2020] [Accepted: 11/26/2020] [Indexed: 11/30/2022] Open
Abstract
The ideal immunosuppressive regimen should provide for excellent immunosuppression with no side effects. Yet, current immunosuppressive therapy regimens commonly used in clinical applications fail to meet this criterion. One of the complications caused by immunosuppressive drugs is mineralization disorders in hard tissues. In this study, we evaluated the effects of three immunosuppressive therapies used after transplantation on the levels of potassium, iron, chromium, zinc, aluminum, sodium and molybdenum in the bones and teeth of female rats and their offspring. The study was conducted on 32 female Wistar rats, subjected to immunosuppressive regimens (cyclosporine A, mycophenolate mofetil and prednisone; tacrolimus, mycophenolate mofetil and prednisone; and cyclosporine A, everolimus and prednisone). The hard tissues of rats were analyzed using inductively coupled plasma optical emission spectrometry (ICP-OES, ICAP 7400 Duo, Thermo Scientific) equipped with a concentric nebulizer and a cyclonic spray chamber. All the immunosuppressive regimens included in the study affected the concentrations of the studied minerals in hard tissues of female rats and their offspring. The therapy based on cyclosporine A, everolimus and prednisone led to a decline in the levels of iron in bone, zinc in teeth, and molybdenum in the bone and teeth of mothers, while in the offspring, it caused a decline of bone potassium, with a decrease in iron and increase of molybdenum in teeth. Moreover, the regimen caused an increase in aluminum and chromium in the teeth and aluminum in the bones of the offspring, and consequently, it seems to be the therapy with the most negative impact on the mineral metabolism in hard tissues.
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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.
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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.
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Taber-Hight E, Shah S. Acute Kidney Injury in Pregnancy. Adv Chronic Kidney Dis 2020; 27:455-460. [PMID: 33328061 DOI: 10.1053/j.ackd.2020.06.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/07/2020] [Accepted: 06/09/2020] [Indexed: 11/11/2022]
Abstract
Acute kidney injury in pregnancy is a public health problem and a significant cause of maternal and fetal morbidity and mortality. The incidence of pregnancy-related acute kidney injury has increased in the developed countries, theorized to be the result of an increase in pregnancies in advanced maternal age, and continues to remain higher in developing countries owing to inadequate antenatal care. While hyperemesis gravidarum is a common cause of pregnancy-related acute kidney injury during the first trimester, complications such as preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, acute fatty liver disease of pregnancy, thrombotic thrombocytopenic purpura, and hemolytic uremic syndrome are important causes of acute kidney injury later in the pregnancy. Diagnosis of pregnancy-related acute kidney injury can be difficult owing to lack of diagnostic criteria and overlapping clinical features between various causes. General measures to treat pregnancy-related acute kidney injury include identification of the underlying cause of kidney injury, intravenous fluid resuscitation, timely initiation of dialysis if needed, and prompt fetal delivery, if necessary. Specific treatment includes steroid and immunosuppressive therapy for glomerulonephritis; prompt delivery for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and acute fatty liver of pregnancy; and plasmapheresis and eculizumab for thrombotic microangiopathies such as thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome.
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Drozdowska-Szymczak A, Szpotanska-Sikorska M, Czaplinska N, Borek-Dzieciol B, Schreiber-Zamora J, Mazanowska N, Pietrzak B, Wielgos M, Kociszewska-Najman B. Evaluation of selected parameters of immune response to rubella virus, hepatitis B virus and varicella-zoster virus infections in children born to mothers after kidney or liver transplantation. J Matern Fetal Neonatal Med 2020; 35:3365-3372. [PMID: 32928004 DOI: 10.1080/14767058.2020.1818219] [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: 10/23/2022]
Abstract
BACKGROUND The immune status of children exposed prenatally to immunosuppressants is not fully understood. MATERIAL AND METHODS A single-center study evaluated possible differences in antibody levels between children prenatally exposed to immunosuppressants born to mothers after hepatic or kidney transplantation (study group) compared to children without prenatal exposure to immunosuppressants (control group). Children from the study and control group were age-matched at the time of the examination and gestational age-matched, so as to obtain similar stages of the vaccination schedule and to enable reliable comparison of the results. The selection of children was made in a 1:1 ratio. The study population, a total of 138 children, was divided according to the age of the children at the time of the study into three age groups: newborns, infants (from 29 days to 1 year) and children aged >1 year. Immunoenzymatic tests were used to analyze the titers of the chickenpox virus (VZV-IgG), rubella (RuV-IgG) and hepatitis B virus (HBV, HBsAb). The studied differences were compared depending on the age group and the immunosuppressive regimen used by the pregnant mother. RESULTS In neonates born to mothers after liver transplantation, significant differences were found in HBsAb levels (>250 mIU/ml) compared to newborns without prenatal exposure to immunosuppressants taken by pregnant mothers (11/16, 69% vs. 4/14, 29%, respectively; p = .028). A similar difference in the level of HbsAb was no longer noted at later stages of children's lives. In infants, these values were 80% (4/5) vs. 33% (2/6), and in children over 1 year of age 15% (7/48) vs. 12% (6/49), respectively. No other significant differences were noted when compared the distribution of measured parameters of VZV and RuV in both analyzed groups (children of mothers after kidney or liver transplantation chronically treated with immunosuppression and children without prenatal exposure to immunosuppression). CONCLUSIONS Prenatal exposure to immunosuppressive therapy does not appear to affect VZV, RuV and HBV antibody levels in children of mothers who have had a kidney or liver transplant. Initially elevated HBSAb levels in newborns of mothers after liver transplantation are not observed in later stages of life.
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Affiliation(s)
| | | | - Natalia Czaplinska
- Department of Neonatology, Children's Hospital, Medical University of Warsaw, Warsaw, Poland
| | - Beata Borek-Dzieciol
- Department of Neonatology, Children's Hospital, Medical University of Warsaw, Warsaw, Poland
| | - Joanna Schreiber-Zamora
- Department of Neonatology, Children's Hospital, Medical University of Warsaw, Warsaw, Poland
| | - Natalia Mazanowska
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Bronislawa Pietrzak
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
| | - Mirosław Wielgos
- 1st Department of Obstetrics and Gynecology, Medical University of Warsaw, Warsaw, Poland
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Abstract
Chronic rheumatic diseases often occur in women of reproductive age, and the effect rheumatic disease has on pregnancy varies depending on the condition. Medical management of rheumatic diseases during pregnancy may prevent joint or organ damage and minimize the adverse effects of the disease itself on pregnancy outcomes. Each patient requires individual assessment to control disease activity while minimizing or avoiding medications with potential maternal or fetal toxicity. An open discussion with shared decision making between patients, obstetricians, rheumatologists, and pharmacists is imperative to create an individualized treatment plan that meets patients' goals. This article will review the current literature for use of disease modifying antirheumatic drugs and biologics during pregnancy and lactation, providing health care professionals with the most up-to-date information available.
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Arabi Z, Ghalib B, Asmari I, Gafar M, Alam S, Abdulgadir M, AlShareef A, Rashidi A, Alruwaymi M, Altheaby A. Instructions for kidney recipients and donors (In English for medical providers and in Arabic for patients and donors). Avicenna J Med 2020; 10:41-53. [PMID: 32110549 PMCID: PMC7014992 DOI: 10.4103/ajm.ajm_120_19] [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] [Indexed: 11/18/2022] Open
Abstract
Medical providers are often asked by their kidney recipients and donors about what to do or to avoid. Common questions include medications, diet, isolation, return to work or school, pregnancy, fasting Ramadan, or hajj and Omrah. However, there is only scant information about these in English language and none in Arabic. Here, we present evidence-based education materials for medical providers (in English language) and for patients and donors (in Arabic language). These educational materials are prepared to be easy to print or adopt by patients, providers, and centers.
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Affiliation(s)
- Ziad Arabi
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Basmeh Ghalib
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Ibrahim Asmari
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed Gafar
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Syed Alam
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohamad Abdulgadir
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Ala AlShareef
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Awatif Rashidi
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Mohammed Alruwaymi
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Abdulrahman Altheaby
- Adult Transplant Nephrology, The Organ Transplant Center at King Abdulaziz Medical City, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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Banerjee K, Singla B. Successful retrieval of oocytes from renal transplant recipient followed by surrogacy. Indian J Nephrol 2020; 30:50-51. [PMID: 32015603 PMCID: PMC6977381 DOI: 10.4103/ijn.ijn_37_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/17/2019] [Accepted: 05/07/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Bhavana Singla
- Advance Fertility and Gynecology Centre, New Delhi, India
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Shah S, Christianson AL, Meganathan K, Leonard AC, Schauer DP, Thakar CV. Racial Differences and Factors Associated with Pregnancy in ESKD Patients on Dialysis in the United States. J Am Soc Nephrol 2019; 30:2437-2448. [PMID: 31554657 DOI: 10.1681/asn.2019030234] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 08/23/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Pregnancy in women with ESKD undergoing dialysis is uncommon due to impaired fertility. Data on pregnancy in women on dialysis in the United States is scarce. METHODS We evaluated a retrospective cohort of 47,555 women aged 15-44 years on dialysis between January 1, 2005 and December 31, 2013 using data from the United States Renal Data System with Medicare as primary payer. We calculated pregnancy rates and identified factors associated with pregnancy. RESULTS In 47,555 women on dialysis, 2352 pregnancies were identified. Pregnancy rate was 17.8 per thousand person years (PTPY) with the highest rate in women aged 20-24 (40.9 PTPY). In the adjusted time-to-event analysis, a higher likelihood of pregnancy was seen in Native American (HR, 1.77; 95% CI, 1.33 to 2.36), Hispanic (HR, 1.51; 95% CI, 1.32 to 1.73), and black (HR, 1.33; 95% CI, 1.18 to 1.49) women than in white women. A higher rate of pregnancy was seen in women with ESKD due to malignancy (HR, 1.64; 95% CI, 1.27 to 2.12), GN (HR, 1.38; 95% CI, 1.21 to 1.58), hypertension (HR, 1.32; 95% CI, 1.16 to 1.51), and secondary GN/vasculitis (HR, 1.18; 95% CI, 1.02 to 1.37) than ESKD due to diabetes. A lower likelihood of pregnancy was seen among women on peritoneal dialysis than on hemodialysis (HR, 0.47; 95% CI, 0.41 to 0.55). CONCLUSIONS The pregnancy rate is higher in women on dialysis than previous reports indicate. A higher likelihood of pregnancy was associated with race/ethnicity, ESKD cause, and dialysis modality.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology, Kidney C.A.R.E. (Clinical Advancement, Research and Education) Program, University of Cincinnati, Cincinnati, Ohio;
| | | | | | | | - Daniel P Schauer
- Internal Medicine, University of Cincinnati, Cincinnati, Ohio; and
| | - Charuhas V Thakar
- Division of Nephrology, Kidney C.A.R.E. (Clinical Advancement, Research and Education) Program, University of Cincinnati, Cincinnati, Ohio.,Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio
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Yuksel Y, Yuksel D, Yucetin L, Erbis H, Sarier M, Karatas O, Emek M, Erdogan M, Yavuz A, Demirbas A. Use of Tacrolimus During Pregnancy After Kidney Transplantaion. Transplant Proc 2019; 51:2361-2366. [DOI: 10.1016/j.transproceed.2019.01.150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 01/31/2019] [Indexed: 11/24/2022]
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Abstract
Advancement in kidney transplantation has led to prolonged survival in our population with kidney disease. Newer agents of immunosuppression have made this possible with less rejections and lesser opportunistic infections and transplant related deaths. Preventative care like timely vaccines, cancer screenings, aggressive blood pressure, blood sugar, lipid control, timely referral to consultants is required in these patient population to provide quality care and to prolong their survival. Primary care physicians are the best advocate for our transplant populations. To care for these complex transplant patients, it is vital for primary care physicians to be familiar with the overall approach on our patients.
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Affiliation(s)
- Kavitha Ramaswamy
- Thomas Jefferson University Hospital, Division of Nephrology, 833 Chestnut St, Suite 700, Philadelphia, PA 19107, USA.
| | - Hector M Madariaga
- Good Samaritan Medical Center, Department of Medicine, 235N Pearl St, Brockton, MA 02301, USA
| | - Beje S Thomas
- Georgetown University Medical Center, MedStar Georgetown Transplant Institute, 3800 Reservoir Road, Washington, DC 20007 USA
| | - Edgar V Lerma
- University of Illinois at Chicago College of Medicine/ Advocate Christ Medical Center, Oak Lawn, IL, USA
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Shah S, Christianson AL, Verma P, Meganathan K, Leonard AC, Schauer DP, Thakar CV. Racial disparities and factors associated with pregnancy in kidney transplant recipients in the United States. PLoS One 2019; 14:e0220916. [PMID: 31398243 PMCID: PMC6688836 DOI: 10.1371/journal.pone.0220916] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/25/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Although kidney transplant improves reproductive function in women with end-stage kidney disease (ESKD), pregnancy in kidney transplant recipients' remains challenging due to the risk of adverse maternal and fetal outcomes. METHODS We evaluated a retrospective cohort of 7,966 women who were aged 15-45 years and received a kidney transplant between January 1, 2005 and December 31, 2011 from the United States Renal Data System with Medicare as the primary payer for the entire three years after the date of transplantation. Unadjusted and adjusted rates of pregnancy in the first three post-transplant years were calculated, using Poisson regression for the adjustment. Factors associated with pregnancy, including race, were examined using logistic regression. RESULTS Overall, 293 pregnancies were identified in 7966 women. The unadjusted pregnancy rate was 13.8 per thousand person-years (PTPY) (95% confidence interval (CI), 12.3-15.5). Pregnancy rates were roughly constant in the years 2005-2011 except in 2005 and 2010. The rate of pregnancy was highest in Hispanic women (21.4 PTPY; 95% CI, 17.2-26.4) and Hispanic women had a higher likelihood of pregnancy as compared to white women (OR, 1.56; CI, 1.12-2.16). Pregnancy rates were lowest in women aged 30-34 years and 35-45 years at transplant, and women aged 30-34 years and 35-45 years at transplant were less likely to ever become pregnant during the follow-up (odds ratio [OR], 0.69; CI, 0.49-0.98 and OR, 0.14; CI 0.09-0.21 respectively) as compared to women aged 25-29 years at time of transplant. Women had higher rates of pregnancy in the second and third-year post-transplant (16.0 PTPY, CI 13.2-19.2 and 16.9 PTPY, CI 14.0-20.4) than in the first-year post-transplant (9.0 PTPY, CI 7.0-11.4). In transplant recipients, pregnancy was more likely in women with ESKD due to cystic disease (OR, 2.42; CI, 1.02-5.74) or glomerulonephritis (OR, 2.14; CI, 1.07-4.31) as compared to women with ESKD due to diabetes. CONCLUSION Hispanic race, younger age, and ESKD cause due to cystic disease or glomerulonephritis are significant factors associated with a higher likelihood of pregnancy. Pregnancy rates have been fairly constant over the last decade. This study improves our understanding of factors associated with pregnancy in kidney transplant recipients.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, Ohio, United States
| | - Annette L. Christianson
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio, United States
| | - Prasoon Verma
- Division of Neonatology, Cincinnati Children’s Hospital and Medical Center, Cincinnati, Ohio, United States
| | - Karthikeyan Meganathan
- Department of Biomedical Informatics, University of Cincinnati, Cincinnati, Ohio, United States
| | - Anthony C. Leonard
- Department of Family and Community Medicine, University of Cincinnati, Cincinnati, Ohio, United States
| | - Daniel P. Schauer
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, United States
| | - Charuhas V. Thakar
- Division of Nephrology Kidney C.A.R.E. Program, University of Cincinnati, Cincinnati, Ohio, United States
- Division of Nephrology, VA Medical Center, Cincinnati, Ohio, United States
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Hortu I, Arı SA, Akdemir A, Koroglu OA, Yılmaz M, Toz H, Sagol S, Ergenoglu AM. Perinatal outcomes of renal transplant pregnancies: a 22-year experience at a single tertiary referral center. J Matern Fetal Neonatal Med 2019; 33:3028-3034. [PMID: 31288677 DOI: 10.1080/14767058.2019.1639664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background: Renal transplantation not only prolongs survival but also improves quality of life and fertility, particularly in patients with end-stage renal disease. The aim of this study was to evaluate the renal and perinatal outcomes of pregnancy after renal transplantation at a high volume academic tertiary hospital.Methods: Fifty-one renal transplant patients (RTPs) who experienced pregnancy after transplantation and received care at Ege University Hospital between January 1995 and December 2017 were retrospectively identified. Data on demographics, comorbidities, and clinical perinatal outcomes were analyzed.Results: The median age of expectant mothers with renal transplantation was 30.51 ± 5.28 years (range 23-41). The mean interval between discontinuing birth control methods and the last menstrual period was 22 months. Preeclampsia occurred in six pregnancies (11.5%), and 43 of 52 pregnancies resulted in live births (82.6%). The mean gestational age at birth was 36.35 ± 2.36 weeks (range: 26-38). A total of 15 births were preterm deliveries (28.8%). Intrauterine growth retardation (IUGR) was detected in four cases. The mean birth weight was 2664.58 ± 613.99 g (range: 600-3.800 g). Twelve newborns were hospitalized in the neonatal intensive care unit (23%). A significant inverse correlation between birth weight and preconception serum creatinine level was found (p < .001; r = -0.532). An inverse correlation between the interval between transplantation and pregnancy and low postpartum serum creatinine level was established significantly (p < .05; r = -0.331). In addition, an inverse correlation between preconceptional serum creatinine and postpartum serum creatinine in the first year was found statistically significant (p < .001, r = -0.681).Conclusion: Even though pregnancy does not seem to adversely affect renal graft function, risks of perinatal as well as obstetrical complications should not be ignored. Pregnancies in RTPs should be followed closely by a multidisciplinary team of experts to minimize perinatal complications before and during pregnancy.
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Affiliation(s)
- Ismet Hortu
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Sabahattin Anıl Arı
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Ali Akdemir
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Ozge Altun Koroglu
- Department of Pediatrics, Division of Neonatology, Ege University School of Medicine, Izmir, Turkey
| | - Mumtaz Yılmaz
- Department of Internal Medicine, Division of Nephrology, Ege University School of Medicine, Izmir, Turkey
| | - Huseyin Toz
- Department of Internal Medicine, Division of Nephrology, Ege University School of Medicine, Izmir, Turkey
| | - Sermet Sagol
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - A Mete Ergenoglu
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
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Kosoku A, Uchida J, Maeda K, Yoshikawa Y, Hamuro A, Shimada H, Kabei K, Nishide S, Iwai T, Kuwabara N, Naganuma T, Kumada N, Takemoto Y, Nakatani T. Successful pregnancy after in vitro fertilization in an ABO-incompatible kidney transplant recipient receiving rituximab: a case report. BMC Nephrol 2019; 20:206. [PMID: 31170923 PMCID: PMC6554973 DOI: 10.1186/s12882-019-1396-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 05/24/2019] [Indexed: 11/11/2022] Open
Abstract
Background Successful pregnancy outcomes after in vitro fertilization in kidney transplant recipients have been reported, but few cases of successful pregnancy after ABO-incompatible kidney transplantation have been described. Herein, we report on a successful pregnancy after in vitro fertilization in an ABO-incompatible kidney transplant recipient with rituximab, focusing on the changes in immunity. Case presentation A 35-year-old woman with end-stage kidney disease caused by IgA nephropathy was referred for kidney transplantation and successfully underwent an ABO-incompatible living-donor kidney transplant using rituximab from her 66-year-old father at the age of 36. Because she and her husband desired childbearing, they received fertility treatments, and embryo cryopreservation was performed before transplantation. Two years after the transplant, she desired pregnancy. Although immunoglobulin levels such as IgG, IgA and IgM had recovered to almost normal range, the peripheral CD19+ cells and CD20+ cells remained depleted. At 6 months after conversion from mycophenolate mofetil to azathioprine, frozen embryo transfer was performed during the hormone replacement cycle. At 37 weeks and 4 days gestation, a healthy baby girl weighing 2220 g was delivered by cesarean section for arrest of labor. There were no complications in both the recipient and her baby during the perinatal period. At 5 years after the transplant, the recipient has had no major complications including rejection or infection. Conclusions It is possible for women receiving ABO-incompatible kidney transplantation with rituximab to successfully become pregnant and deliver a heathy baby after in vitro fertilization, if IgG levels recover to normal range despite depleted peripheral blood B cells.
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Affiliation(s)
- Akihiro Kosoku
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Junji Uchida
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Keiko Maeda
- Department of Nursing, Osaka City University Hospital, 1-5-7, Asahi-machi, Abeno-ku, Osaka, 545-8586, Japan
| | - Yuki Yoshikawa
- Osaka City University Medical School Skills Simulation Center, 1-2-7, Asahi-machi, Abeno-ku, Osaka, 545-0051, Japan
| | - Akihiro Hamuro
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Hisao Shimada
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kazuya Kabei
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shunji Nishide
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tomoaki Iwai
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Nobuyuki Kuwabara
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Toshihide Naganuma
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Norihiko Kumada
- Department of Urology, Suita Municipal Hospital, 2-13-20, Katayama-cho, Suita-shi, Osaka, 564-0082, Japan
| | - Yoshiaki Takemoto
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tatsuya Nakatani
- Department of Urology, Osaka City University Graduate School of Medicine, 1-4-3, Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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Yun BH, Joo DJ, Seo SK, Cho SH, Choi YS, Lee BS. Effect of deflazacort on pregnancy outcome in kidney transplant patients: should we change the immunosuppressant before conception? BMC Nephrol 2019; 20:161. [PMID: 31088388 PMCID: PMC6515635 DOI: 10.1186/s12882-019-1346-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 04/18/2019] [Indexed: 01/26/2023] Open
Abstract
Background Despite the good prognosis in patients with transplant organs, limited evidence is available on how immunosuppressants affect pregnancy. The aim of this study was to determine whether immunosuppressant use affects the pregnancy outcome and to identify whether there is any need to change the immunosuppressant before the patient tries to conceive. Methods This retrospective cohort study included women with previous kidney transplantation history who visited the Department of Obstetrics and Gynecology for either infertility or antenatal care between January 2005 and May 2016. A total of 40 cases (36 women) met the inclusion criteria. Statistical analyses were performed using SAS version 9.4. Results There were no differences in the immunosuppressant regimen between the pregnant and non-pregnant groups (never-pregnant+miscarriage) (P = 0.73). Individual immunosuppressant use was significantly different in terms of pregnancy outcome among the never-pregnant, miscarriage, and clinical pregnancy groups (azathioprine, P = 0.01; deflazacort, P < 0.0001). Only deflazacort use differed significantly between the clinical pregnancy and non-pregnant groups (P = 0.003). After adjusting for factors that may affect pregnancy outcome, deflazacort use remained significantly associated with a decreased odds ratio for clinical pregnancy (P = 0.02). Cox regression analysis also showed that deflazacort use was the only remaining factor that could hinder the success of clinical pregnancy (P = 0.03). Conclusions Our study suggests that the type of immunosuppressive regimen may not affect the success of clinical pregnancy. However, deflazacort may decrease the possibility of clinical pregnancy in women with kidney transplant when they try to conceive.
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Affiliation(s)
- Bo Hyon Yun
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Jin Joo
- Department of Transplant Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok Kyo Seo
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - Si Hyun Cho
- Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea.,Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sik Choi
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Seok Lee
- Department of Obstetrics and Gynecology, Severance Hospital, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Institute of Women's Life Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Abstract
Hypertensive disorders of pregnancy are common and contribute inordinately to maternal and fetal morbidity and mortality. Although not completely understood, recent clinical trials have provided important insights into pathogenesis of preeclampsia. Preeclampsia is considered a systemic disease with generalized endothelial dysfunction and risk of future cardiovascular disease. This review revisits the definitions and classifications of hypertensive disorders of pregnancy; discusses updates on pathophysiology, prevention, and early prediction of preeclampsia; reviews current management guidelines; and discusses potential risks and benefits associated with treatment. Improvement in management and outcomes of women with hypertensive disorders of pregnancy seems in sight in the near future.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology, Kidney CARE Program, University of Cincinnati, 231 Albert Sabin Way, MSB 6211, Cincinnati, OH 45267, USA.
| | - Anu Gupta
- Buffalo Medical Group, 2121 Main Street #305, Buffalo, NY 14214, USA
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50
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