Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review

Risk of severe maternal morbidity and mortality among pregnant patients with chronic kidney disease: Renal disease and severe maternal morbidity

BACKGROUND

Chronic kidney disease is a significant cause of adverse obstetric outcomes. However, there are few studies assessing the risk of severe maternal morbidity and mortality among patients with chronic kidney disease and no studies assessing the association between individual indicators of severe maternal morbidity and chronic kidney disease.

OBJECTIVE

To evaluate the risk of severe maternal morbidity and mortality among pregnant patients with chronic kidney disease.

STUDY DESIGN

This was a population-based, retrospective cohort study including U.S. delivery hospitalizations from 2010-2020 utilizing the Healthcare Cost & Utilization Project National Inpatient Sample database. Patients were identified as having a delivery hospitalization, chronic kidney disease, and severe maternal morbidity using International Classification Diagnoses codes (9th and 10th edition). The primary outcomes were severe maternal morbidity and mortality, as defined according to the Centers for Disease Control and Prevention criteria. Multivariate logistic regression analyses were performed to estimate adjusted relative risk and 95% confidence intervals of severe maternal morbidity and mortality among patients with chronic kidney disease. Subgroup analyses were performed by chronic kidney disease etiology, stage, race and ethnicity, and individual indicators of severe maternal morbidity.

RESULTS

Among the 38,374,326 parturients in this study, 95,272 (0.2%) had chronic kidney disease. The risk of severe maternal morbidity was higher for those with chronic kidney disease (12.2% vs. 0.7%, aRR 6.4, 95% CI 6.0-6.8) compared to those without. Among severe maternal morbidity indicators, those with chronic kidney disease were at highest risk for acute renal failure (aRR 21.7, 95% CI 19.8-23.7) and sepsis (aRR 9.0, 95% CI 7.6-10.5). Chronic kidney disease was also associated with an increased risk of maternal death (aRR 4.1, 95% CI 2.9-5.8). Black individuals had higher adjusted population attributable fraction (aPAF) between severe maternal morbidity and chronic kidney disease (aPAF 4.0%, 95% CI 3.6-4.3). Increased risk of severe maternal morbidity was associated with all chronic kidney disease subtypes, stages, and a history of renal transplant. Maternal death was significantly associated with diabetic nephropathy, renovascular, and obstructive or unspecified renal disease (aRR 7.3-14.1), as well as stages 3-5 of chronic kidney disease and a history of renal transplant (aRR 15.5-32.6). Risk of severe maternal morbidity and mortality were similar in those with a history of renal transplant and those with stage 1 chronic kidney disease. The number needed to treat with renal transplant to prevent one severe maternal morbidity event or maternal death in those with stages 3-5 chronic kidney disease was 2.6 (95% CI 2.4-2.9) and 45.0 (95% CI 31.0-82.0), respectively.

CONCLUSION

Chronic kidney disease in pregnancy was significantly associated with severe maternal morbidity, mortality, and other adverse perinatal outcomes, warranting close surveillance and multidisciplinary management throughout pregnancy.

First successful ovarian cortex allotransplant to a Turner syndrome patient requiring immunosuppression: wide implications

OBJECTIVE

To determine whether we can safely and successfully transplant an ovary tissue allograft from a nonidentical donor to her Turner syndrome sister.

DESIGN

Transplantation of cryopreserved ovary tissue, as well as fresh transplantation of ovarian tissue between identical twins, is now well established with numerous reported successful cases. However, there have not yet been any ovary transplants between nonidentical women requiring immunosuppression (ovary allotransplant). This could be a much more common indication for ovary tissue transplantation if safe and reliable immunosuppression were available.

PATIENT(S)

A 20-year-old amenorrheic woman with nonmosaic 45-XO Turner syndrome requested ovary tissue transplantation from her fertile 22-year-old 46-XX sister. They were an human leukocyte antigens match but were ABO incompatible, a well-known contra-indication to solid tissue or organ transplantation. The Turner syndrome sister strongly preferred to be able to become pregnant naturally without donor egg in vitro fertilization and to avoid hormone replacement therapy. In her religious group, that would also be important for finding a marital match. Despite the poor prognosis associated with ABO incompatibility, an ovary from her 22-year-old nonidentical fertile sister was transplanted to her employing the immunosuppression protocol now used for kidney transplant patients in our centers at Washington University and Johns Hopkins.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Post operatively at 5 months she developed normal monthly menstrual ovarian function, and she became spontaneously pregnant with a normal infant girl. The relation between her postoperation follicle stimulating hormone and antimüllerian hormone levels continue to support the theory that tissue pressure controls primordial follicle recruitment. The fact that ABO incompatibility did not prevent success suggests that diffusion and not revascularization may be all that is required for successful long-term ovarian cortex transplant survival with spontaneous pregnancy.

RESULT(S)

Ovary allotransplantation with safe immunosuppression allows natural conception, and also normal hormone function obviates the need for hormone replacement therapy. Orthotopic placement of the graft and surgical technique is critical for natural conception and a higher pregnancy rate.

CONCLUSION(S)

Allotransplantation requiring safe immunosuppression, if successful, maybe a much more commonly used indication for ovary transplantation in the future than frozen ovary grafts or grafts between identical twins.

Pregnancy occurring in AA amyloidosis: a series of 27 patients including 3 new French cases

BACKGROUND

AA amyloidosis (AAA) is a multisystem disease related to the deposition in tissues of serum amyloid A protein which complicates chronic inflammation. It is a potentially fatal complication.  Renal involvement is the most common manifestation of AAA. Pregnancy in women with chronic kidney disease  is considered to be at risk for specific pregnancy complications and the worsening of their underlying renal dysfunction. Our aim was to report pregnancy in our AAA patients and discuss the outcome through a literature review.

METHODS

French cases were identified through the Reference Center for Auto-Inflammatory Diseases and Amyloidosis and a systematic literature review was performed.

RESULTS

Three new patients were identified: two with Familial Mediterranean fever (FMF) and one with cryopyrin-associated periodic syndrome; one was under anakinra therapy and one had received a kidney transplantation before her pregnancy. One patient was diagnosed with AAA following the detection of post-partum nephrotic syndrome. Among the 27 patients from literature and our case, FMF was the main cause of AAA (69%). Eight of the patients were diagnosed with AAA during their pregnancy or in immediate post-partum and gestational complications appeared in 23/25 cases, mostly intrauterine growth retardation (n = 10), prematurity (n = 11) and preeclampsia (n = 4). No bleeding complication was reported.

CONCLUSION

Pregnancy can occur in patients (eight overall) with AAA and the diagnosis is frequently made during pregnancy. Pregnant women with AAA are at risk for adverse pregnancy-associated outcomes and require special and closer monitoring.

Labor and Delivery Outcomes in Australian Mothers after Kidney Transplantation

Key Points

Background

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

Methods

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

Results

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

Conclusions

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

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

OBJECTIVE

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

SUBJECT AND METHODS

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

RESULTS

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

CONCLUSION

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

Reproductive Health in Kidney Transplant Recipients

Increasing number of women with kidney transplants are of reproductive age and desire successful pregnancies. Successful outcomes of pregnancy can be achieved with preconception counseling, education about contraception use, the timing of pregnancy (delaying by first year post-transplant), and the choice of immunosuppression medication. Ensuring stable renal function including optimized creatinine, proteinuria, and blood pressure increases successful outcomes. Pregnancy with kidney transplant has an increased risk of preeclampsia, gestational diabetes militeus, cesarean section, and preterm delivery. Multidisciplinary cooperation with high-risk obstetrics and transplant nephrologists is vital.

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

Importance

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

Objective

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

Data Sources

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

Study Selection

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

Data Extraction and Synthesis

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Late pregnancy in women with renal transplants: A multidisciplinary guide

Kidney transplant recipients are at risk of complications in late pregnancy, with increased rates of pre-eclampsia, intrauterine growth restriction and preterm birth. It is recommended that these women receive more intensive monitoring after 20 weeks' gestation, ideally provided by a multidisciplinary team in a tertiary centre. This review focuses on the management of late pregnancy in kidney transplant recipients, from the perspective of different members of the multidisciplinary team. This includes evidence and guidance to inform the nephrologist, obstetrician, obstetric anaesthetist, transplant surgeon, midwife, and a summary of the woman's perspective. The review outlines a late pregnancy and early postnatal care pathway as a common algorithm to be used by the whole multidisciplinary team.

Pregnancy outcomes post-kidney transplantation across 23 years

BACKGROUND

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

AIMS

To describe pregnancy outcomes in kidney transplant recipients.

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Pregnancy after transplant in the older adolescent: Anticipatory guidance for the pediatric provider

BACKGROUND

Healthcare providers who care for adolescent and young adult transplant recipients should be aware of contraception counseling and potential for pregnancy in this at-risk cohort.

METHODS

This paper will review contraceptive options in general for transplant recipients. There will also be a review of common immunosuppressive medications and their risk profile regarding pregnancy after transplantation. Data from the Transplant Pregnancy Registry International were analyzed looking at recipients conceiving under the age of 21 and were compared to overall pregnancy outcomes.

RESULTS

Overall pregnancy outcomes in recipients under the age of 21 are like the adult cohort.

CONCLUSION

It is imperative to provide contraception counseling to the adolescent and young adult and inform their caregiver that pregnancy can happen if the recipient is sexually active. Pregnant adolescent and young adult transplant recipients should be followed by a multidisciplinary team to assure a positive outcome for the recipient, transplant, and neonate.

[Obstetrical outcome of renal transplant patients followed in a type III maternity hospital. Retrospective study from 2000 to 2020]

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).

Uterine Artery Pulsatility Index in Pregnant Kidney or Liver Recipients and Its Impact on Perinatal Outcome

BACKGROUND

The uterine artery pulsatility index (UtA PI) is associated with blood flow to the placenta. Its increased values imply impaired placentation. This study aimed to evaluate UtA PI measurements in first-trimester ultrasound in pregnancies after kidney (KTx) or liver transplantation (LTx) and its relationship with perinatal outcome.

MATERIALS AND METHODS

A retrospective analysis of 72 pregnancies in female kidney (35) or liver (37) transplant recipients between 2017 and 2023 was performed. Data concerning UtA PI were available for 17 kidney and 19 liver recipients. Statistical analysis of variables between KTx and LTx groups and the correlation with perinatal outcomes was performed using Student's t test and Pearson's correlation with P < .05 considered statistically significant.

RESULTS

The mean UtA PI results were similar, and there were no statistical differences between the group of pregnant kidney and liver recipients with mean values of 1.46 (SD 0.44] and 1.73 (SD 0.51] respectively (P = .10). The mean neonate birth weight was lower in KTx group (2158 g ([SD 723 g]) compared with the LTx group (2780 g [SD 754g]; P =.02). In the KTx and LTx groups, mean UtA PI was in negative correlation with Apgar score in the first minute (P = .04, P = .01 respectively).

CONCLUSIONS

Uterine artery Doppler is useful in predicting perinatal outcomes in the general population and organ recipient pregnancies, even in the early stages of pregnancy, as we observed the correlation between UtA PI and Apgar score. Pregnant kidney recipients remain at higher risk for complications and more unpredictable outcomes than liver recipients.

Pre-gestational counselling for women living with CKD: starting from the bright side

Pregnancy in women living with chronic kidney disease (CKD) was often discouraged due to the risk of adverse maternal-fetal outcomes and the progression of kidney disease. This negative attitude has changed in recent years, with greater emphasis on patient empowerment than on the imperative 'non nocere'. Although risks persist, pregnancy outcomes even in advanced CKD have significantly improved, for both the mother and the newborn. Adequate counselling can help to minimize risks and support a more conscious and informed approach to those risks that are unavoidable. Pre-conception counselling enables a woman to plan the most appropriate moment for her to try to become pregnant. Counselling is context sensitive and needs to be discussed also within an ethical framework. Classically, counselling is more focused on risks than on the probability of a successful outcome. 'Positive counselling', highlighting also the chances of a favourable outcome, can help to strengthen the patient-physician relationship, which is a powerful means of optimizing adherence and compliance. Since, due to the heterogeneity of CKD, giving exact figures in single cases is difficult and may even be impossible, a scenario-based approach may help understanding and facing favourable outcomes and adverse events. Pregnancy outcomes modulate the future life of the mother and of her baby; hence the concept of 'post partum' counselling is also introduced, discussing how pregnancy results may modulate the long-term prognosis of the mother and the child and the future pregnancies.

Anemia in Pregnancy With CKD

Chronic kidney disease (CKD), anemia, and iron deficiency are global health issues affecting individuals in both high-income and low-income countries. In pregnancy, both CKD and iron deficiency anemia increase the risk of adverse maternal and neonatal outcomes, including increased maternal morbidity and mortality, stillbirth, perinatal death, preterm birth, and low birthweight. However, it is unknown to which extent iron deficiency anemia contributes to adverse outcomes in CKD pregnancy. Furthermore, little is known regarding the prevalence, pathophysiology, and treatment of iron deficiency and anemia in pregnant women with CKD. Therefore, there are many unanswered questions regarding optimal management with oral or i.v. iron and recombinant human erythropoietin (rhEPO) in these women. In this review, we present a short overview of the (patho)physiology of anemia in healthy pregnancy and in people living with CKD. We present an evaluation of the literature on iron deficiency, anemia, and nutritional deficits in pregnant women with CKD; and we evaluate current knowledge gaps. Finally, we propose research priorities regarding anemia in pregnant women with CKD.

Gender and kidney transplantation

Kidney transplantation provides the best form of kidney replacement therapy with improvement in quality of life and longevity. However, disparity exists in its availability, utilisation and outcomes, not only due to donor availability or financial constraints but also arising from the influence of biological sex and its sociocultural attribute i.e., Gender. Women make up the majority of kidney donors but are less likely to be counselled regarding transpantation, be waitlisted or receive living/deceased donor kidney. Biological differences also contribute to differences in kidney transplantation among the sexes. Women are more likely to be sensitised owing to pregnancy, especially in multiparous individuals, complicating donor compatibility. A heightened immune system in women, evidenced by more autoimmune illnesses, increases the risk of allograft rejection and loss. Differences in the pharmacokinetics of transplant drugs owing to biological variances could also contribute to variability in outcomes. Transgender medicine is also increasingly becoming a relevant topic of study, providing greater challenges in the form of hormonal manipulations and anatomic changes. It is thus important to determine and study transplantation and its nuances in this backdrop to be able to provide relevant sex and gender-specific interventions and design better practices for optimum kidney transplant utilisation and outcomes.

Successful Twin Delivery Through In Vitro Fertilization in a High-Gestation Age Kidney Transplant Recipient: A Case Report

BACKGROUND

Numerous successful pregnancy outcomes have been reported after kidney transplantation, but until now, there have been no reports of healthy twin deliveries through in vitro fertilization treatment in high-gestation aged women with a long post-transplant duration. In our report, we present a case of a high-gestation aged kidney transplant recipient who successfully delivered healthy twins with the aid of in vitro fertilization.

CASE PRESENTATION

At the age of 29, a woman with end-stage kidney disease caused by immunoglobin A nephropathy underwent kidney transplantation. She had a history of premature ovarian failure and had been on continuous ambulatory peritoneal dialysis since the age of 18. Eleven years after starting dialysis, she received a cadaveric kidney transplant. Despite being infertile for 7 years after transplantation, she wished to have children. In vitro fertilization embryo transfer was conducted after failure of ovarian stimulation, considering her age and premature ovarian failure. The patient successfully delivered twins at 29 weeks gestation via cesarean section, as the first fetus presented in breech position. The first newborn weighed 945 g and the second weighed 855 g, with no other congenital abnormalities found. One year after childbirth, neither the recipient nor her babies experienced any fatal complications.

CONCLUSIONS

A woman who underwent kidney transplantation and has stage 3 CKD may successfully deliver healthy twins through in vitro fertilization embryo transfer, even if she is of advanced maternal age and has a long post-transplant period. However, there is a risk of preterm premature rupture of membrane in such cases.

Pregnancy after kidney transplantation: 40 years single-center experience

BACKGROUND

Kidney transplantation (KT) improves quality of life, including fertility recovery.

OBJECTIVE

to describe outcomes of post-KT pregnancy and long-term patient and graft survival compared to a matched control group of female KT recipients who did not conceive.

METHODS

retrospective single-center case-control study with female KT recipients from 1977 to 2016, followed-up until 2019.

RESULTS

there were 1,253 female KT patients of childbearing age in the study period: 78 (6.2%) pregnant women (cases), with a total of 97 gestations. The median time from KT to conception was 53.0 (21.5 - 91.0) months. Abortion rate was 41% (spontaneous 21.6%, therapeutic 19.6%), preterm delivery, 32%, and at term delivery, 24%. Pre-eclampsia (PE) occurred in 42% of pregnancies that reached at least 20 weeks. The presence of 2 or more risk factors for poor pregnancy outcomes was significantly associated with abortions [OR 3.33 (95%CI 1.43 - 7.75), p = 0.007] and with kidney graft loss in 2 years. The matched control group of 78 female KT patients was comparable on baseline creatinine [1.2 (1.0 - 1.5) mg/dL in both groups, p = 0.95] and urine protein-to-creatinine ratio (UPCR) [0.27 (0.15 - 0.44) vs. 0.24 (0.02 - 0.30), p = 0.06]. Graft survival was higher in cases than in controls in 5 years (85.6% vs 71.5%, p = 0.012) and 10 years (71.9% vs 55.0%, p = 0.012) of follow-up.

CONCLUSION

pregnancy can be successful after KT, but there are high rates of abortions and preterm deliveries. Pre-conception counseling is necessary, and should include ethical aspects.

Pregnancies in Women With Kidney Failure on Home Dialysis in the United States

Introduction

Women with kidney failure have impaired fertility and are at a higher risk of maternal and fetal morbidity and mortality. Little is known about pregnancies in women receiving maintenance home dialysis in the United States.

Methods

Using data from the United States Renal Data System (USRDS), a cohort of 26,387 women aged 15 to 49 years with kidney failure receiving maintenance home dialysis from 2005 to 2018 was examined. We calculated pregnancy rates and identified factors, including the modality associated with pregnancy receiving home dialysis.

Results

Overall, 437 pregnancies were identified in 26,837 women on home dialysis. The unadjusted pregnancy rate was 8.6 per 1000 person-years (PTPY). The unadjusted pregnancy rate was higher on home hemodialysis (16.0 vs. 7.5 PTPY) than on peritoneal dialysis. Women receiving home hemodialysis had a higher adjusted likelihood of pregnancy than women receiving peritoneal dialysis (hazard ratio [HR], 2.34; 95% confidence interval [CI], 1.79-3.05). Compared with women aged 20 to 24 years, the likelihood of pregnancy was lower in women aged 30 to 34 years (HR, 0.64; 95% CI, 0.43-0.96), 35 to 39 years (HR, 0.53; 95% CI, 0.35-0.79), 40 to 44 years (HR, 0.32; 95% CI, 0.21-0.49), and 45 to 49 years (HR, 0.21; 95% CI, 0.13-0.33). Whereas Black women had a higher likelihood of pregnancy (HR, 1.40; 95% CI, 1.07-1.83), there was no difference in likelihood of pregnancy in Asian, Hispanic, and Native Americans as compared to Whites. Body mass index, cause of kidney failure, socioeconomic status, rurality, predialysis nephrology care, or dialysis vintage were not significantly associated with pregnancy on home dialysis.

Conclusion

The pregnancy rate in women with kidney failure undergoing home dialysis is higher with home hemodialysis than with peritoneal dialysis. Younger age and Black race or ethnicity are associated with a higher likelihood of pregnancy among women receiving home dialysis. This information can guide clinicians in preconception counselling and making informed treatment decisions for pregnant women on home dialysis.

Azathioprine Associated with Intrahepatic Cholestasis in a Patient with Twin Pregnancy after a Second Kidney Transplant

Introduction

Most pregnancies in women after a kidney transplant result in a live birth, but kidney functions should be stable for one year before conception. For immunosuppression modification occurring before pregnancy, azathioprine is used because it is considered safe for major congenital malformations during pregnancy. However, there may be an association between exposure to azathioprine during pregnancy and the onset of an unusual, early and severe form of intrahepatic cholestasis.

Case description

A young patient with a twin pregnancy after a second kidney transplant experienced intrahepatic cholestasis. There was a wide range of differential diagnosis. A battery of tests was requested including autoimmune markers, virology, and imaging. The conclusion that azathioprine was contributing to intrahepatic cholestasis with pregnancy was reached after exclusion of all other differentials.

Conclusions

Complications of pregnancy after a kidney transplant include hypertension, pre-eclampsia, deterioration of graft function up to rejection, but also unusual side effects of immunosuppression medication.

LEARNING POINTS

A twin pregnancy after a second kidney transplant is rare.In addition to bone marrow suppression and elevation of liver enzymes, azathioprine can contribute to intrahepatic cholestasis of pregnancy.Complications of pregnancy after kidney transplant include hypertension, pre-eclampsia, deterioration of graft function up to rejection, but also unusual side effects of immunosuppression medication.

Maternal and neonatal outcomes for kidney transplant recipients

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thoracic organ transplantation and pregnancy outcomes: systematic review and meta-analysis

PURPOSE

Pre-conceptual comorbidities, an inherent risk of graft loss, rejection during pregnancy, and the postpartum period in women with thoracic lung transplant may predispose them to increased risk of adverse feto-maternal outcomes. The study aimed to systematically analyze and assess the risk of adverse pregnancy outcomes in women with thoracic organ transplant.

METHODS

MEDLINE, EMBASE, and Cochrane library were searched for publication between January 1990 and June 2020. Risk of bias was assessed using Joanna Briggs critical appraisal tool for case series. The primary outcomes included maternal mortality and pregnancy loss. The secondary outcomes were maternal complications, neonatal complications, and adverse birth outcomes. The analysis was performed using the DerSimonian-Laird random effects model.

RESULTS

Eleven studies captured data from 275 parturient with thoracic organ transplant describing 400 pregnancies. The primary outcomes included maternal mortality {pooled incidence (95% confidence interval) 4.2 (2.5-7.1) at 1 year and 19.5 (15.3-24.5) during follow-up}. Pooled estimates yielded 10.1% (5.6-17.5) and 21.8% (10.9-38.8) risk of rejection and graft dysfunction during and after pregnancy, respectively. Although 67% (60.2-73.2) of pregnancies resulted in live birth, total pregnancy loss and neonatal death occurred in 33.5% (26.7-40.9) and 2.8% (1.4-5.6), respectively. Prematurity and low birth weight were reported in 45.1% (38.5-51.9) and 42.7% (32.8-53.2), respectively.

CONCLUSIONS

Despite pregnancies resulting in nearly 2/3rd of live births, high incidence of pregnancy loss, prematurity and low birth weight remain a cause of concern. Focused pre-conceptual counseling to avoid unplanned pregnancy, especially in women with transplant-related organ dysfunctions and complications, is vital to improve pregnancy outcomes.

PROSPERO NUMBER

CRD42020164020.

Postpartum hemorrhage with associated placenta previa in a kidney transplant recipient: A case report

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.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

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

DATA SOURCES AND METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

PROSPERO (CRD42024541659).

Prevalence of infertility and pregnancy loss among individuals with kidney disease in the Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanic/Latino individuals are less likely to receive optimal treatment for chronic kidney disease than non-Hispanic whites. This may be particularly detrimental for women of reproductive age as chronic kidney disease increases risk for infertility, menstrual irregularities, and pregnancy loss. While these maternal outcomes have been associated with advanced chronic kidney disease, their occurrence in early chronic kidney disease is unclear.

OBJECTIVES/DESIGN

Using baseline (2008-2011) and second study visit (2014-2017) data from the Hispanic Community Health Study/Study of Latinos, we retrospectively assessed the prevalence of chronic kidney disease as well as the association between chronic kidney disease and self-reported infertility, cessation of menses, hysterectomy, and nonviable pregnancy loss (experienced at less than 24 weeks gestation) in women of reproductive age (18-45 years).

METHODS

Multivariable survey logistic regression analyses determined the unadjusted and multivariable-adjusted prevalence odds ratios with 95% confidence intervals between chronic kidney disease and the separate outcomes.

RESULTS

Among 2589 Hispanic/Latino women included (mean age = 31.4 years), 4.6% were considered to have chronic kidney disease. In adjusted analyses, women with chronic kidney disease did not have a significantly increased odds of infertility (odds ratio = 1.02, 95% confidence interval = 0.42-2.49), cessation of menses (odds ratio = 1.25, 95% confidence interval = 0.52-3.04), or hysterectomy (odds ratio = 1.17, 95% confidence interval = 0.61-2.25) compared to those without chronic kidney disease. In those with chronic kidney disease, the adjusted odds of a nonviable pregnancy loss occurring after baseline visit were increased (odds ratio = 2.11, 95% confidence interval = 0.63-7.02) but not statistically significance.

CONCLUSION

The presence of early stage chronic kidney disease did not confer a significant risk of infertility, cessation of menses, or nonviable pregnancy loss.

Patient and Partner Perspectives of Pregnancy-Related Counseling and Information Needs in Women With Kidney Disease: An Australian National Survey

Introduction

The experiences and information needs for reproductive health counseling in women with chronic kidney disease (CKD) are poorly defined, despite the known importance of pregnancy planning in this higher-risk cohort.

Methods

Australian adult women with CKD and their partners or family members completed a consumer codesigned survey about experiences of and preferences for pregnancy-related counseling, support, and education. Data were analyzed descriptively and with qualitative content analysis of free-text responses.

Results

Responses were received from 102 women (CKD, n = 60; dialysis, n = 11; transplant, n = 26; unsure, n = 5 ) and 17 partners/family members. Pregnancy-related discussions were initiated mostly by women themselves (60.0%) compared to nephrologists (26.7%), and only after conception in 14.7%. Women found pregnancy-related discussions satisfactory (68.0%) and useful (50.7%) but also stressful (66.7%), with only 54.7% feeling in control of decision-making. Information deficits and quality, preformed decisions, clinician-patient disconnect, and burden of decision-making contributed to usefulness and outcomes of pregnancy-related counseling. Women received insufficient information about contraception (not provided in 35.2% of cases), medication safety (40.9%), fetal complications (33.8%) and emotional and psychological impact of pregnancy (73.2%). Women preferred counseling from nephrologists (86.4%), face-to-face settings (79.6%), websites (72.7%), handouts (61.4%), and online support groups (46.6%). High-quality, multiformat information by content experts, peer support, and psychological support were also strongly desired.

Conclusion

This study highlights that preconception counseling and information needs of women with CKD are currently not being met. Frameworks and tools to assist patients and clinicians, particularly nephrologists, to initiate and conduct sensitive, useful, and informed shared decision-making (SDM) about pregnancy are urgently needed.

Dialysis and a plant-based diet to achieve physiologic urea levels for fetal benefit: Normal pregnancy outcome despite chronic kidney disease and hypertension

Chronic kidney disease significantly increases the risk of adverse maternal and perinatal outcomes. A growing body of evidence suggests that intensive dialysis, achieving physiologic pre-dialysis blood urea, is associated with decreased morbidity. We report a case of a successful pregnancy outcome in a 32-year-old nulliparous woman with stage 4 chronic kidney disease who underwent haemodialysis from 11 to 31 weeks' gestation for fetal benefit and concurrently trialled a plant-based diet. We hypothesise that her dietary changes assisted with urea reduction, enabling her to become dialysis independent. Although we must recognise that such pregnancies remain high risk, as demonstrated both in this case and more recent literature, advances in complex obstetric care and dialysis protocols may now give women with chronic kidney disease a realistic hope of a successful pregnancy.

Contraceptive Use in Females With Advanced CKD: A Qualitative Study

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.

Placental histopathology and correlated clinical outcomes in kidney transplant recipients

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

Outcomes With Belatacept Exposure During Pregnancy in Kidney Transplant Recipients: A Case Series

BACKGROUND

Posttransplant fertility returns quickly, and female recipients of child-bearing age may conceive while on immunosuppression. However, pregnancy after transplantation confers risks to the recipient, transplant, and fetus, including gestational hypertension, preeclampsia, gestational diabetes, transplant dysfunction, preterm labor, and low birthweight infants. Additionally, mycophenolic acid (MPA) products are teratogenic. Literature evidence regarding belatacept, a selective T-cell costimulation blocker, during pregnancy and while breastfeeding is extremely limited. When female transplant recipients on a belatacept-based regimen are desirous of pregnancy or at the time of conception, transplant providers manage the immunosuppression regimen in 1 of 2 ways: (1) switch both belatacept and MPA to a calcineurin inhibitor-based regimen with or without azathioprine, which is the more common practice but requires several modifications, having potential negative outcomes; or (2) only switch MPA to azathioprine while continuing belatacept.

METHODS

This case series includes 16 pregnancies in 12 recipients with exposure to belatacept throughout pregnancy and while breastfeeding. Patient information was obtained from several sources, including Transplant Pregnancy Registry International, providers at Emory University, and Columbia University, as well as literature review.

RESULTS

Pregnancy outcomes included 13 live births and 3 miscarriages. No birth defects or fetal deaths were reported in any of the live births. Seven infants were breastfed while their mothers continued belatacept. Outcomes appear comparable to those documented with the administration of calcineurin inhibitors.

CONCLUSIONS

This case series provides data supporting the continued administration of belatacept during pregnancy. Additional research will assist in developing better guidelines to counsel female transplant recipients on belatacept desiring to pursue pregnancy.

Pregnancy after kidney transplantation: an observational study on maternal, graft and offspring outcomes in view of current literature

Introduction

Pregnancy after kidney transplantation (KTx) is considered to have a high risk of non-negligible complications for the mother, the allograft, and the offspring. With an increased incidence of these pregnancies over the past decades, transplant nephrologists and specialized obstetricians face increasing challenges, with scarce literature regarding long-term outcomes.

Methods

We retrospectively collected data from all women with at least one live birth pregnancy after KTx who were followed at our tertiary hospital between 2000 and 2021 to study maternal, graft and fetal outcomes.

Results

Ten patients underwent 14 live birth pregnancies after KTx. Preponderant maternal complications were stage 1 acute kidney injury (43%), urinary tract infections (UTI, 43%), progression of proteinuria without diagnostic criteria for preeclampsia (29%), and preeclampsia (14%). Median baseline serum creatinine at conception was 126.5 µmol/L [median estimated glomerular filtration rate (eGFR) 49 mL/min/1.73m2], and eGFR tended to be lower than baseline at follow-ups. Overall, there was no increase in preexisting or occurrence of de novo donor-specific antibodies. No graft loss was documented within the 2-year follow-up. There were nine premature births (64%), with a median gestational age of 35.7 weeks. The median birth weight, height, and head circumference were 2,560 g, 45.5 cm, and 32.1 cm, respectively. These measurements tended to improve over time, reaching a higher percentile than at birth, especially in terms of height, but on average remained under the 50th percentile curve.

Discussion

Overall, pregnancies after KTx came with a range of risks for the mother, with a high prevalence of cesarean sections, emergency deliveries, UTI, and preeclampsia, and for the child, with a high proportion of prematurity, lower measurements at birth, and a tendency to stay under the 50th percentile in growth charts. The short- and long-term impact on the allograft seemed reassuring; however, there was a trend toward lower eGFR after pregnancy. With these data, we emphasize the need for a careful examination of individual risks via specialized pre-conception consultations and regular monitoring by a transplant nephrologist and a specialist in maternal-fetal medicine during pregnancy. More data about the long-term development of children are required to fully apprehend the impact of KTx on offspring.

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

Background

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

Methods

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

Results

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

Conclusions

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Counselling on Conceiving: Attitudes and Factors Influencing Advice of Professionals in Transplantation

Pregnancy after kidney transplantation (KT) conveys risks of adverse pregnancy outcomes (APO). Little is known about performance of pre-pregnancy counselling after KT. This study investigated perceptions of risk, attitudes towards pregnancy and factors influencing advice given at pre-pregnancy counselling after KT. A web-based vignette survey was conducted among nephrologists and gynaecologists between March 2020 and March 2021, consisting of five vignettes containing known risk factors for APO and general questions on pre-pregnancy counselling after KT. Per vignette, attitudes towards pregnancy and estimation of outcomes were examined. In total 52 nephrologists and 25 gynaecologists participated, 56% from university hospitals. One third had no experience with pregnancy after KT. All gave positive pregnancy advice in the vignette with ideal circumstances (V1), versus 83% in V2 (proteinuria), 81% in V3 (hypertension), 71% in V4 (eGFR 40 ml/min/1.73 m²). Only 2% was positive in V5 (worst-case scenario). Chance of preeclampsia was underestimated by 89% in V1. 63% and 98% overestimated risk for graft loss in V4 and V5. Professionals often incorrectly estimated risk of APO after KT. As experience with pregnancy after KT was limited among professionals, patients should be referred to specialised centres for multidisciplinary pre-pregnancy counselling to build experience and increase consistency in given advice.

Infertility, pregnancy and breastfeeding in kidney transplantation recipients: Key issues

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.

Fetal endothelial colony-forming cell impairment after maternal kidney transplantation

BACKGROUND

Successful pregnancies are nowadays possible after kidney transplantation but are associated with a higher incidence of maternal and fetal complications. Immunosuppressive therapy causes cardiovascular side effects but must be maintained during pregnancy. Little is known about the consequences of maternal kidney transplantation on offspring's endothelial health. Endothelial colony forming cells (ECFCs) represent a highly proliferative subtype of endothelial progenitor cells and are crucial for vascular homeostasis, repair and neovascularization. Therefore, we investigated whether maternal kidney transplantation affects fetal ECFCs' characteristics.

METHODS

ECFCs were isolated from umbilical cord blood of uncomplicated and post-kidney-transplant pregnancies and analyzed for their functional abilities with proliferation, cell migration, centrosome orientation and angiogenesis assays. Further, ECFCs from uncomplicated pregnancies were exposed to either umbilical cord serum from uncomplicated or post-kidney-transplant pregnancies.

RESULTS

Post-kidney-transplant ECFCs showed significantly less proliferation, less migration and less angiogenesis compared to control ECFCs. The presence of post-kidney-transplant umbilical cord serum led to similar functional aberrations of ECFCs from uncomplicated pregnancies.

CONCLUSIONS

These pilot data demonstrate differences in ECFCs' biological characteristics in offspring of women after kidney transplantation. Further studies are needed to monitor offspring's long-term cardiovascular development and to assess possible causal relationships with immunosuppressants, uremia and maternal cardiovascular alterations.

IMPACT

Pregnancy after kidney transplantation has become more common in the past years but is associated with higher complications for mother and offspring. Little is known of the impact of maternal kidney transplantation and the mandatory immunosuppressive therapy on offspring vascular development. In this study we are the first to address and detect an impairment of endothelial progenitor cell function in offspring of kidney-transplanted mothers. Serum from post-transplant pregnancies also causes negative effects on ECFCs' function. Clinical studies should focus on long-term monitoring of offspring's cardiovascular health.

Reproductive health after thoracic transplantation: An ISHLT expert consensus statement

Pregnancy after thoracic organ transplantation is feasible for select individuals but requires multidisciplinary subspecialty care. Key components for a successful pregnancy after lung or heart transplantation include preconception and contraceptive planning, thorough risk stratification, optimization of maternal comorbidities and fetal health through careful monitoring, and open communication with shared decision-making. The goal of this consensus statement is to summarize the current evidence and provide guidance surrounding preconception counseling, patient risk assessment, medical management, maternal and fetal outcomes, obstetric management, and pharmacologic considerations.

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

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

A survey of solid organ transplant recipient attitudes and concerns regarding contraception and pregnancy

INTRODUCTION

Many women who are solid organ transplant (SOT) recipients wish to have children after transplantation. Contraception is an important component of post-transplant planning and care, given the increased risk associated with post-transplant pregnancies. We sought to understand patient attitudes and concerns about post-transplant contraception and pregnancy.

METHODS

Following a comprehensive literature review, our team developed a survey that was administered to female SOT recipients of childbearing age. We used descriptive and inferential statistics to characterize participant views RESULTS: A total of 243 transplant recipients completed the survey (80.7% response rate). The mean age of respondents was 37.5 years (±8.1 years), 66.7% were kidney recipients, and 40.7% were within the first year after transplant. The most common concerns among respondents included fetal and maternal health complications. Participants generally did not agree that transplant recipients should be advised to avoid pregnancy. There was strong support for shared decision-making about pregnancy after transplantation CONCLUSION: Understanding patient perspectives can help transplant providers make better care recommendations and support patient autonomy in reproductive decisions post-transplant. Given that there are some differences in views by transplant type, individualized conversations between patients and providers are needed.

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

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

Emergent prelabor cesarean delivery in solid organ transplant recipients: associated risk factors and outcomes

BACKGROUND

Pregnancies after solid organ transplant are at a higher risk of antepartum admission and pregnancy complications including cesarean delivery. Emergent prelabor cesarean delivery is associated with increased maternal and neonatal morbidity in other high-risk populations, but its incidence and impact in transplant recipients is not well-understood.

OBJECTIVE

This study aimed to characterize the risk factors and outcomes of emergency prelabor cesarean delivery in kidney and liver transplant recipients.

STUDY DESIGN

This was a retrospective cohort study of all kidney and liver transplant recipients at >20 weeks gestation enrolled in the Transplant Pregnancy Registry International between 1976 and 2019. Participants admitted antepartum who required emergency prelabor cesarean delivery were compared with those admitted antepartum who underwent nonemergent birth. The primary outcomes were severe maternal morbidity and neonatal composite morbidity. Multivariable logistic regression was conducted for neonatal composite morbidity.

RESULTS

Of 1979 births, 181 pregnancies (188 neonates) with antepartum admission were included. 51 pregnancies (53 neonates, 28%) were delivered by emergent prelabor cesarean delivery compared with 130 pregnancies (135 neonates, 72%) admitted antepartum who subsequently did not require emergent delivery. The most common indication for emergent delivery was nonreassuring fetal heart tracing (44 pregnancies /51 emergent deliveries = 86%). Pregnant people who underwent emergent prelabor cesarean delivery were less likely to deliver at a transplant center (37.3% vs 41.5%; P=.04) and had increased rates of chronic hypertension (33.3% vs 16.2%; P=.02). There was no significant difference in severe maternal morbidity (3.9% vs 4.6%; P=.84), though there was an increase in surgical site infection in the emergent prelabor cesarean delivery cohort (3.9% vs 0%; P=.02). Among those with emergent prelabor cesarean delivery, there was a significant increase in neonatal composite morbidity (43.4% vs 19.3%; P<.001) with earlier gestational age at delivery (33.4 vs 34.7 weeks; P=.02), lower birthweight (1899 g vs 2321 g; P<.001), lower birthweight percentile (30.3% vs 40.6%; P=.03), increased neonatal intensive care unit admission (52.8% vs 35.6%; P=.03), and increased neonatal mortality (11.3% vs 1.5%; P=.002). After adjusting for year of conception, race, hypertensive disorders, and fetal malformations, there was a persistent increased risk of neonatal morbidity (adjusted odds ratio, 3.01; 95% confidence interval, 1.50-6.08; P=.002) associated with emergent prelabor cesarean delivery after transplant.

CONCLUSION

Almost one-third of kidney and liver transplant recipients admitted antepartum had an emergency prelabor cesarean delivery, and 63% of this cohort delivered outside of a transplant center. Pregnancies after transplantation should involve multidisciplinary transplant-obstetrics collaboration to ensure optimal antepartum disease management, especially for preexisting hypertension, to prevent and mitigate obstetrical and neonatal morbidity in the setting of emergent cesarean delivery.

Correlations between Maternal and Fetal Outcomes in Pregnant Women with Kidney Failure

BACKGROUND

Kidney function impairment in pregnancy is challenging, with incidence and prognosis only partially known. Studies concerning maternal and fetal outcomes in pregnancies occurring in patients with renal injury and the therapeutic strategies for improving the prognosis of these patients are scarce due to the limited number of cases reported.

OBJECTIVES

We aimed to establish correlations between the main maternal and fetal outcomes in patients with severe CKD or AKI in pregnancy to improve the prognosis, referring to a control group of patients with mild kidney impairment.

METHODS

For this purpose, we conducted a retrospective study, at University Emergency Hospital in Bucharest, Romania, from January 2019 until December 2021, selecting 38 patients with AKI and 12 patients diagnosed with advanced CKD, compared to 42 patients displaying borderline values of serum creatinine (0.8-1 mg/dL), reflecting the presence of milder kidney impairment.

RESULTS

The probability of having a child that is premature and small for gestational age, with a lower Apgar score and more frequent neonatal intensive care unit admissions, delivered by cesarean section, is higher in patients with highly reduced kidney function.

CONCLUSION

Severe kidney function impairment is associated with a grim fetal prognosis and obstetrical complications.

[Outcome of neonates born to mothers with chronic kidney disease]

About 3% of pregnant women suffer from chronic kidney disease (CKD). This article reviews the literature on the outcomes of neonates born to mothers with CKD (including those undergoing dialysis and kidney transplantation), and the results show that CKD during pregnancy may increase the risk of preterm birth, low birth weight, and small for gestational age infant, but it does not increase the risk of congenital anomalies. As for long-term outcomes, CKD during pregnancy has no significant impact on offspring's physical development and immune function. Neurodevelopmental outcome of offspring is associated with preterm birth and low birth weight, rather than intrauterine drug exposure. However, further research and follow-up are needed to investigate the outcome of neonates born to mothers with CKD.

Pregnancy Complications and Impact on Kidney Allograft After Kidney Transplantation in IgA Nephropathy

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.

[PREGNANCIES IN KIDNEY TRANSPLANT RECIPIENTS, AN ANALYSIS OF 9 CASES]

(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.

Systematic review of pregnancy and renal outcomes for women with chronic kidney disease receiving assisted reproductive therapy

BACKGROUND

As awareness around infertility is increasing among patients with chronic kidney disease (CKD), ever more of them are seeking Assisted Reproductive Technology (ART). Our aim was to perform a systematic review to describe obstetric and renal outcomes in women with CKD following ART.

METHODS

The following databases were searched from 1946 to May 2021: (1) Cochrane Central Register of Controlled Trials (CENTRAL), (2) Cumulative Index to Nursing and Allied Health Literature (CINAHL), (3) Embase and (4) MEDLINE.

RESULTS

The database search identified 3520 records, of which 32 publications were suitable. A total of 84 fertility treatment cycles were analysed in 68 women. Median age at time of pregnancy was 32.5 years (IQR 30.0, 33.9 years). There were 60 clinical pregnancies resulting in 70 live births (including 16 multifetal births). Four women developed ovarian hyperstimulation syndrome which were associated with acute kidney injury. Hypertensive disorders complicated 26 pregnancies (38.3%), 24 (35.3%) pregnancies were preterm delivery, and low birth weight was present in 42.6% of pregnancies. Rates of live birth and miscarriage were similar for women with CKD requiring ART or having natural conception. However, more women with ART developed pre-eclampsia (p < 0.05) and had multifetal deliveries (p < 0.001), furthermore the babies were lower gestational ages (p < 0.001) and had lower birth weights (p < 0.001).

CONCLUSION

This systematic review represents the most comprehensive assessment of fertility outcomes in patients with CKD following ART. However, the high reported live birth rate is likely related to reporting bias. Patient selection remains crucial in order to maximise patient safety, screen for adverse events and optimise fertility outcomes.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A multi-institutional study of renal outcomes and renal-related pregnancy outcomes in uterus transplant recipients

Uterus transplantation (UTx) is an effective treatment option for uterine factor infertility. However, the need for immunosuppression and congenital renal anomalies that coexist with uterine agenesis in about 30% of women with Mayer-Rokitansky-Kuster-Hauser syndrome create a risk for renal dysfunction. We therefore examined renal function trajectory and related pregnancy complications in an international cohort of 18 UTx recipients from September 2016-February 2020 who had at least one live birth. All UTx recipients had a diminution in their renal function that was apparent starting at 30 days posttransplant and in half the reduction in eGFR was at least 20%; the decrease in eGFR persisted into the early post-partum period. Half met criteria for Stage 1 acute kidney injury (AKI) as defined by the AKI Network criteria during their pregnancy. Overall, 28% of UTx recipients developed pre-eclampsia. eGFR was lower at embryo transfer and throughout pregnancy among those who developed pre-eclampsia, reaching statistical significance at week 16 of pregnancy. This effect was independent of tacrolimus levels. Mean eGFR remained significantly lower in the first 1-3 months after delivery. In the subgroup who reached 12 months of postpartum follow up and had a graft hysterectomy (n = 4), there was no longer a statistical difference in eGFR (pretransplant 106.7 ml/m ± 17.7 vs. 12 mos postpartum 92.6 ml/m ± 21.7, p = .13) but the number was small. Further study is required to delineate long term renal risks for UTx recipients, improve patient selection, and make decisions regarding a second pregnancy.

Proteomic study on the lymphocytes from pregnant Wistar rat females treated with immunosuppressive regimen

Kidney transplantation remains the therapeutic option for patients with end-stage kidney disease. Current immunosuppressive regimens are efficient in combating acute kidney rejection. However, insights into chronic kidney allograft injury remains limited. Simultaneously, pregnancy is more common after kidney transplantation than during dialysis treatment. Due to ethical issues, comprehensive studies on the impact of immunosuppressive regimens on pregnancy are challenging. The study aimed to investigate the proteomic status of lymphocytes obtained from pregnant female rats under immunosuppressive treatment. The experiment involved a group of 10 female, pregnant Wistar rats, five of which were treated with tacrolimus, mofetil mycophenolate, and glucocorticosteroids; five were used as control. The lymphocytes were obtained and analyzed with mass spectrometry. Measurements were processed by a database search in the ProteinPilot software with a cutoff of 1% false discovery rate. The outcomes were verified statistically by a t-test (p value < 0.05) regarding proteins up- and downregulation. A total of 2082 proteins were identified in all experiments. Eight hundred five proteins were quantified in an absolute manner in a data-independent acquisition-total protein approach analysis. Ninety-five proteins were recognized as present at different concentrations in analyzed groups and were annotated to intracellular pathways. The proteins involved in nonsense-mediated decay and L13a-mediated translational silencing of ceruloplasmin expression were recognized as downregulated. The set of proteins clinically identified as acute phase proteins was upregulated. Despite the blockade of adaptive cellular immunity, the lymphocytes in the analyzed group reveal sustained proinflammatory status with decreased ability to regulate translation. This potentially affects pregnancy and immunity.