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Radaelli E, Meinerz G, Jacobina LP, Bruno RM, de Andrade JAM, Garcia VD, Keitel E. Pregnancy after kidney transplantation: 40 years single-center experience. J Bras Nefrol 2024; 46:e20230061. [PMID: 38078833 PMCID: PMC11210546 DOI: 10.1590/2175-8239-jbn-2023-0061en] [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: 08/03/2023] [Accepted: 10/12/2023] [Indexed: 03/21/2024] Open
Abstract
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.
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Affiliation(s)
- Eloísa Radaelli
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Patologia, Porto Alegre, RS, Brazil
| | - Gisele Meinerz
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Patologia, Porto Alegre, RS, Brazil
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Rosana Mussoi Bruno
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Patologia, Porto Alegre, RS, Brazil
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | - Juliana Alves Manhães de Andrade
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Patologia, Porto Alegre, RS, Brazil
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Elizete Keitel
- Universidade Federal de Ciências da Saúde de Porto Alegre, Programa de Pós-Graduação em Patologia, Porto Alegre, RS, Brazil
- Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
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2
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Amado FC, de Oliveira AP, Hamamoto TENK, Araujo E, Guazzelli CAF. Hormonal intrauterine device in women with renal transplantation: a prospective observational study. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e20230352. [PMID: 37729224 PMCID: PMC10511283 DOI: 10.1590/1806-9282.20230352] [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: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE The main objective of this study is to evaluate the rate of continuity and satisfaction with hormonal intrauterine device in renal transplant recipients. METHODS This was a prospective observational study. The sample consisted of patients treated at a Family Planning Outpatient Clinic, from August 2016 to September 2021. Information on each patient's age, parity, and associated diseases as well as satisfaction with the method were analyzed. Patients were invited to participate through electronic messages, and the questionnaire included questions about acceptance of the contraceptive method. RESULTS A total of 40 patients were included in the study. The mean age of the renal transplant patients was 32.5 years. The mean duration of hormonal intrauterine device use was 37 months. Acceptance of the method was high, with 97.5% of patients remaining on the method for 1 year and 85% of patients using the hormonal intrauterine device at the time of the study. There were no pregnancies or renal transplant complications in the study. Regarding satisfaction with the method, the majority (77.5%) scored 10. CONCLUSION Patients were satisfied or very satisfied with the hormonal intrauterine device. Therefore, the continuation rate was high. Furthermore, this contraceptive method proved to be safe and effective in kidney transplant recipients. No complications, graft rejection, or graft failure were observed after intrauterine hormonal device insertion and during follow-up.
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Affiliation(s)
- Fernanda Costa Amado
- Universidade Federal de São Paulo, Paulista School of Medicine, Department of Obstetrics – São Paulo (SP), Brazil
| | - Anelisa Pinotti de Oliveira
- Universidade Federal de São Paulo, Paulista School of Medicine, Department of Obstetrics – São Paulo (SP), Brazil
| | | | - Edward Araujo
- Universidade Federal de São Paulo, Paulista School of Medicine, Department of Obstetrics – São Paulo (SP), Brazil
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3
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Chung K, Yin O, Kallapur A, Bass L, Coscia L, Constantinescu S, Moritz M, Afshar Y. Emergent prelabor cesarean delivery in solid organ transplant recipients: associated risk factors and outcomes. Am J Obstet Gynecol MFM 2023; 5:100799. [PMID: 36368514 DOI: 10.1016/j.ajogmf.2022.100799] [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: 07/24/2022] [Revised: 10/19/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Kathleen Chung
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Ophelia Yin
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Aneesh Kallapur
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Lauren Bass
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar)
| | - Lisa Coscia
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz)
| | - Serban Constantinescu
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz); Section of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA (Dr Constantinescu)
| | - Michael Moritz
- Transplant Pregnancy Registry International, Gift of Life Institute, Philadelphia, PA (Ms Coscia and Drs Constantinescu and Moritz); Department of Surgery, Lehigh Valley Health Network, Allentown, PA (Dr Moritz); Department of Surgery, Morsani College of Medicine, Tampa, FL (Dr Moritz)
| | - Yalda Afshar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA (Drs Chung, Yin, and Kallapur, Ms Bass, and Dr Afshar).
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4
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Servais A, Janssen MCH, Blakey H, Greco M, Lemoine S, Martin-Moreno PL, Game D, Levtchenko E, Lipkin G. Pregnancy in cystinosis patients with chronic kidney disease: A European case series. J Inherit Metab Dis 2022; 45:963-968. [PMID: 35713960 DOI: 10.1002/jimd.12529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 05/17/2022] [Accepted: 06/15/2022] [Indexed: 11/11/2022]
Abstract
Cystinosis is a rare autosomal recessive disease leading to end-stage renal disease within the second or third decade of life. Since the era of specific treatment with cysteamine, prognosis has substantially improved and pregnancy becomes an increasing concern. Pregnancy data in patients with cystinosis were collected through an anonymized survey. We collected data for 19 pregnancies in 12 women. Seventeen patients were transplanted, 1 was on hemodialysis and 1 had chronic kidney disease (CKD) stage 4. These 19 pregnancies resulted in 13 live births (68.4%): 3 spontaneous early miscarriages, 1 ectopic pregnancy, 1 early pre-eclampsia (at 21 weeks), and 1 preterm birth with neonatal death at 24 weeks were reported. After exclusion of early miscarriage or termination, pregnancy success rate was 86.7%. In successful pregnancies, median gestational age at delivery was 34 weeks (24-37). Preeclampsia occurred in seven pregnancies (7/15, 46.7%). A cesarean section was performed in all pregnancies. Median baby weight at delivery was 2175 g (620-3374 g). After pregnancy, one patient reached end-stage renal disease, but she already had advanced CKD before pregnancy (creatinine 239 μmol/L, eGFR 23 ml/min/1.73 m2 ). In three other patients, there was a decrease of eGFR of 8, 20, and 53 ml/min/1.73 m2 , respectively. The majority of pregnancies were successful, but severe antenatal and post-natal complications may occur, in particular preeclampsia that was noticed in nearly half of patients and fetal loss in one-third of them. These results may help pre-pregnancy counseling and pregnancy management.
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Affiliation(s)
- Aude Servais
- Nephrology and Transplantation Department, Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Necker Hospital, APHP, Université de Paris, Paris, France
| | - Mirian C H Janssen
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Hannah Blakey
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Marcella Greco
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Sandrine Lemoine
- Nephrology and Renal Function Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, University of Lyon, Centre de Reference des Maladies Rénales et Phosphocalciques Rares Néprhogones, Lyon, France
| | - Paloma L Martin-Moreno
- Department of Nephrology, Clinica Universidad de Navarra, Navarra Institute for Health Research (IdiSNA), Pamplona, Spain
| | - David Game
- Department of Nephrology and Transplantation, Guy's and St Thomas' Hospital, London, UK
| | - Elena Levtchenko
- Division of Pediatric Nephrology, University Hospitals Leuven & Department of Development and Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Graham Lipkin
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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5
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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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6
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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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7
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Koenjer LM, Meinderts JR, van der Heijden OWH, Lely T, de Jong MFC, van der Molen RG, van Hamersvelt HW. Comparison of pregnancy outcomes in Dutch kidney recipients with and without calcineurin inhibitor exposure: a retrospective study. Transpl Int 2021; 34:2669-2679. [PMID: 34797607 PMCID: PMC9299975 DOI: 10.1111/tri.14156] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 09/23/2021] [Accepted: 11/04/2021] [Indexed: 01/29/2023]
Abstract
Within pregnancies occurring between 1986 and 2017 in Dutch kidney transplant recipients (KTR), we retrospectively compared short‐term maternal and foetal outcomes between patients on calcineurin inhibitor (CNI) based (CNI+) and CNI‐free immunosuppression (CNI−). We identified 129 CNI+ and 125 CNI− pregnancies in 177 KTR. Demographics differed with CNI+ having higher body mass index (P = 0.045), shorter transplant‐pregnancy interval (P < 0.01), later year of transplantation and ‐pregnancy (P < 0.01). Serum creatinine levels were numerically higher in CNI+ in all study phases, but only reached statistical significance in third trimester (127 vs. 105 µm; P < 0.01), where the percentual changes from preconceptional level also differed (+3.1% vs. −2.2% in CNI−; P = 0.05). Postpartum both groups showed 11–12% serum creatinine rise from preconceptional level. Incidence of low birth weight (LBW) tended to be higher in CNI+ (52% vs. 46%; P = 0.07). Both groups showed equal high rates of preterm delivery. Using CNIs during pregnancy lead to a rise in creatinine in the third trimester but does not negatively influence the course of graft function in the first year postpartum or direct foetal outcomes. High rates of preterm delivery and LBW in KTR, irrespective of CNI use, classify all pregnancies as high risk.
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Affiliation(s)
- Lisanne M Koenjer
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jildau R Meinderts
- Department of Nephrology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Titia Lely
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Margriet F C de Jong
- Department of Nephrology, University Medical Center Groningen, Groningen, the Netherlands
| | - Renate G van der Molen
- Department of Laboratory Medicine, Laboratory for Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Henk W van Hamersvelt
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
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8
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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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9
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Iltis AS, Mehta M, Sawinski D. Ignorance is Not Bliss: The Case for Comprehensive Reproductive Counseling for Women with Chronic Kidney Disease. HEC Forum 2021:10.1007/s10730-021-09463-7. [PMID: 34617168 DOI: 10.1007/s10730-021-09463-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 10/20/2022]
Abstract
The bioethics literature has paid little attention to matters of informed reproductive decision-making among women of childbearing age who have chronic kidney disease (CKD), including women who are on dialysis or women who have had a kidney transplant. Women with CKD receive inconsistent and, sometimes, inadequate reproductive counseling, particularly with respect to information about pursuing pregnancy. We identify four factors that might contribute to inadequate and inconsistent reproductive counseling. We argue that women with CKD should receive comprehensive reproductive counseling, including information about the possibility of pursuing pregnancy, and that more rigorous research on pregnancy in women with CKD, including women on dialysis or who have received a kidney transplant, is warranted to improve informed reproductive decision making in this population.
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Affiliation(s)
- Ana S Iltis
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA.
| | - Maya Mehta
- Center for Bioethics, Health and Society, Wake Forest University, Winston-Salem, NC, USA
| | - Deirdre Sawinski
- Renal Electrolyte, and Hypertension Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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10
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Ponticelli C, Zaina B, Moroni G. Planned Pregnancy in Kidney Transplantation. A Calculated Risk. J Pers Med 2021; 11:jpm11100956. [PMID: 34683097 PMCID: PMC8537874 DOI: 10.3390/jpm11100956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/23/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022] Open
Abstract
Pregnancy is not contraindicated in kidney transplant women but entails risks of maternal and fetal complications. Three main conditions can influence the outcome of pregnancy in transplant women: preconception counseling, maternal medical management, and correct use of drugs to prevent fetal toxicity. Preconception counseling is needed to prevent the risks of an unplanned untimely pregnancy. Pregnancy should be planned ≥2 years after transplantation. The candidate for pregnancy should have normal blood pressure, stable serum creatinine <1.5 mg/dL, and proteinuria <500 mg/24 h. Maternal medical management is critical for early detection and treatment of complications such as hypertension, preeclampsia, thrombotic microangiopathy, graft dysfunction, gestational diabetes, and infection. These adverse outcomes are strongly related to the degree of kidney dysfunction. A major issue is represented by the potential fetotoxicity of drugs. Moderate doses of glucocorticoids, azathioprine, and mTOR inhibitors are relatively safe. Calcineurin inhibitors (CNIs) are not associated with teratogenicity but may increase the risk of low birth weight. Rituximab and eculizumab should be used in pregnancy only if the benefits outweigh the risk for the fetus. Renin-angiotensin system inhibitors, mycophenolate, bortezomib, and cyclophosphamide can lead to fetal toxicity and should not be prescribed to pregnant women.
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Affiliation(s)
- Claudio Ponticelli
- Nephrology, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Correspondence:
| | - Barbara Zaina
- Department of Obstetrics and Gynecology, IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Gabriella Moroni
- Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Humanitas University, 20122 Milan, Italy;
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11
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Kallapur A, Jang C, Yin O, Mei JY, Afshar Y. Pregnancy care in solid organ transplant recipients. Int J Gynaecol Obstet 2021; 157:502-513. [PMID: 34245162 DOI: 10.1002/ijgo.13819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/28/2021] [Accepted: 07/08/2021] [Indexed: 12/12/2022]
Abstract
Recipients of solid organ transplants who become pregnant represent an obstetrically high-risk population. Preconception planning and effective contraception tailored to the individual patient are critical in this group. Planned pregnancies improve both maternal and neonatal outcomes and provide a window of opportunity to mitigate risk and improve lifelong health. Optimal management of these pregnancies is not well defined. Common pregnancy complications after transplantation include hypertension, preterm birth, infection, and metabolic disease. Multidisciplinary preconception and prepartum management, and counseling decrease complications and benefit the maternal-neonatal dyad.
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Affiliation(s)
- Aneesh Kallapur
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Christine Jang
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Ophelia Yin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Jenny Y Mei
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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12
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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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13
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Egerup P, Carlson N, Bruun Oestergaard L, Blanche P, Scott JR, Hornum M, Torp-Pedersen C, Christiansen OB. Increased risk of neonatal complications and infections in children of kidney-transplanted women: A nationwide controlled cohort study. Am J Transplant 2021; 21:1171-1178. [PMID: 32786135 DOI: 10.1111/ajt.16259] [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: 02/21/2020] [Revised: 07/30/2020] [Accepted: 07/31/2020] [Indexed: 01/25/2023]
Abstract
Information related to short- and long-term risks of children born to kidney-transplanted women remains limited. With the aim of investigating the risk of neonatal complications, and the short- and long-term risk of infections in offspring of kidney-transplanted women, all children born to kidney-transplanted women in Denmark from 1964 to 2016 were identified in a nationwide retrospective matched cohort study. A total of 124 children of kidney-transplanted women were identified and matched on gender, birth year, and number of siblings at birth 1:10 with children born to nontransplanted women identified in the Danish general population. Prevalence of low birth weight (37.9%, risk ratio [RR] = 12.61; 95% confidence interval [CI], 8.5-18.5), premature birth (46.0%, RR = 11.32; 95% CI, 8.1-15.7) and malformations (11.3%, RR = 1.98; 95% CI, 1.2-3.4) was increased in children of kidney-transplanted women compared with controls. Similarly, prevalence of hospitalization due to infection was increased during the first year of life (21.0%, RR = 1.94; 95% CI, 1.3-2.8), from age 1 to 5 (34.2%, RR = 1.89; 95% CI, 1.4-2.5), and overall (41.9%, RR = 1.67; 95% CI, 1.3-2.1). The risk of infection was also higher in children of kidney-transplanted mothers born preterm or with low birth weight compared with similar controls. In conclusion, risk of neonatal complications, malformations, and both early and late infection were increased in children born to kidney-transplanted women.
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Affiliation(s)
- Pia Egerup
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Obstetrics and Gynaecology, Hvidovre Hospital, Copenhagen University Hospital, Hvidovre, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark.,The Research Department, The Danish Heart Foundation, Copenhagen, Denmark
| | | | - Paul Blanche
- Department of Cardiology, Herlev-Gentofte Hospital, Hellerup, Denmark.,Department of Public Health, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - James R Scott
- Department of Obstetrics and Gynaecology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Mads Hornum
- Department of Nephrology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Ole Bjarne Christiansen
- Department of Obstetrics and Gynaecology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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14
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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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15
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Cherniak V, Demir KK, Sandal S, Cantarovich M, Podymow T, Naessens V, Ponette V, Wou K, Do AT, Malhamé I. Thrombotic Microangiopathy in a Pregnant Woman With Kidney Transplantation: A Case Report. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:874-878. [PMID: 33310162 DOI: 10.1016/j.jogc.2020.10.018] [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: 08/18/2020] [Revised: 10/28/2020] [Accepted: 10/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND The differential diagnosis of thrombotic microangiopathy (TMA) in pregnancy includes common conditions, such as preeclampsia. In women with kidney transplantation, additional causes of TMA must be considered. CASE A 22-year-old primigravid woman with a transplanted kidney presented with fetal growth restriction, hypertension, acute kidney injury, and hemolysis at 28 weeks gestation. While her clinical presentation was initially consistent with preeclampsia, hemolysis persisted beyond 1 week postpartum. Diagnoses of TMA associated with tacrolimus and antibody-mediated rejection were considered. An elevated tacrolimus level likely contributed to her TMA and a decrease in dosage improved her clinical picture and laboratory markers. CONCLUSION We report the case of a pregnant kidney transplant recipient with TMA. A multidisciplinary approach is required to optimize the maternal health outcomes in this complex population.
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Affiliation(s)
- Vladimir Cherniak
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | - Koray K Demir
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | - Shaifali Sandal
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | | | - Tiina Podymow
- Department of Medicine, McGill University Health Centre, Montréal, QC
| | | | - Vincent Ponette
- Department of Obstetrics and Gynaecology, McGill University Health Centre, Montréal, QC
| | - Karen Wou
- Department of Obstetrics and Gynaecology, McGill University Health Centre, Montréal, QC
| | - Anh Thu Do
- Department of Pharmacy, McGill University Health Centre, Montréal, QC
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montréal, QC; Research Institute of the McGill University Health Centre, Montréal, QC.
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16
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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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17
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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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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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19
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SARGIN A, KARAMAN S, CEYLAN Ş, AKDEMİR A, HORTU İ. Retrospective evaluation of anesthetic techniques in pregnant women with renal
transplantation. Turk J Med Sci 2019; 49:1736-1741. [PMID: 31655526 PMCID: PMC7518678 DOI: 10.3906/sag-1905-59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 10/17/2019] [Indexed: 02/05/2023] Open
Abstract
Background/aim The aim of this study was to evaluate anesthesia management in cesarean operation of pregnant women who underwent renal transplantation and the effects on postoperative renal function, retrospectively. Materials and methods After obtaining the approval of the ethics committee of our hospital, the records of pregnant women who underwent kidney transplantation and cesarean section between 2007 and 2017 were retrospectively analyzed. The patients’ demographic data, concomitant disease history, the treatment received, and type of anesthesia were retrospectively evaluated and recorded in the follow-up form. Results It was found that a total of 47 women who underwent renal transplantation had 47 live births by cesarean section. The mean age of the pregnant women was 30 ± 5.34 years. The mean time between renal transplantation and conception was 95.34 ± 55.02 months. It was found that 14 (29%) of a total of 47 patients had their first pregnancy. The number of patients with a gravidity of 4 and above was 9 (19%). A total of 21 (44.7%) pregnant women had spontaneous miscarriage. Five (10.6%) patients were treated with curettage for therapeutic purposes. Twenty-two (46%) of the patients whose immunosuppressive therapy was continuing were treated with azathioprine, tacrolimus, and prednisolone. The mean gestational age of delivery was 36.5 ± 1.59 weeks. The rate of prepregnancy hypertension diagnosis was 25.5% (n = 12), while the rate of developing gestational hypertension was 21.3% (n = 10). Spinal anesthesia was administered to 42 (91%) of 47 patients who underwent cesarean section. In the preoperative period, the mean value of serum blood urea nitrogen was 62.88 ± 41.97 mg/dL and the mean serum creatinine level was 3.21 ± 6.17 mg/dL. In the postoperative period, these values were 44.4 ± 29.9 mg/dL and 1.91 ± 1.63 mg/dL, respectively. When the pre- and postoperative serum urea and creatinine levels were compared, they were found to be lower in the postoperative period. However, there was no statistically significant difference (P > 0.05). The mean weight of the newborns was determined as 2707.3 ± 501.5 g. While the number of newborns with a low birth weight (<2500 g) was 18 (38%), among them 3 (0.6%) were below 2000 g. It was found that 36.2% (n = 17) of the newborns required intensive care. None of the patients developed graft rejection. Conclusion If there is no contraindication, regional anesthesia may be preferred in the first place for pregnant women with renal transplantation. We suggest that this method of anesthesia has some advantages in terms of maintaining postoperative renal function and higher Apgar scores in newborns with low birth weight.
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Affiliation(s)
- Asuman SARGIN
- Department of Anesthesiology and Reanimation, School of Medicine, Ege University, İzmirTurkey
| | - Semra KARAMAN
- Department of Anesthesiology and Reanimation, School of Medicine, Ege University, İzmirTurkey
| | - Şeyda CEYLAN
- Department of Anesthesiology and Reanimation, School of Medicine, Ege University, İzmirTurkey
| | - Ali AKDEMİR
- Department of Obstetrics and Gynecology, School of Medicine, Ege University, İzmirTurkey
| | - İsmet HORTU
- Department of Obstetrics and Gynecology, School of Medicine, Ege University, İzmirTurkey
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20
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Maldonado AQ, Hall RC, Pilch NA, Ensor CR, Anders S, Gilarde JA, Tichy EM. ASHP Guidelines on Pharmacy Services in Solid Organ Transplantation. Am J Health Syst Pharm 2019; 77:222-232. [DOI: 10.1093/ajhp/zxz291] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
| | - Reed C Hall
- University Health System, San Antonio, TX
- Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, TX
| | | | | | - Stephanie Anders
- Transplant Pharmacy Services, Ochsner Clinic Foundation, New Orleans, LA
| | | | - Eric M Tichy
- Supply Chain Management, Mayo Clinic, Rochester, MN
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21
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Consecutive Spontaneous Triplet and Twin Pregnancies in a Woman After Renal Transplantation. Transplant Proc 2019; 51:1845-1847. [PMID: 31399169 DOI: 10.1016/j.transproceed.2019.04.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 04/03/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND There are numerous reports of successful pregnancies following kidney transplantation. However, little information is available regarding the management and evolution of multiple pregnancies in a kidney-transplanted woman. CASE REPORT We report the case of successful consecutive spontaneous triplet and twin pregnancies in a woman who had undergone kidney transplantation at 30 years of age, 12 years before the first pregnancy, as a result of end-stage renal disease secondary to chronic glomerulonephritis due to diffuse proliferative lupus nephritis. An integrated multidisciplinary team closely followed progress during the pregnancies. Maternal complications during the pregnancies included light proteinuria, controlled hypertension, and anemia. No graft rejection episodes or deterioration of renal function was noted during the pregnancies or after the deliveries. CONCLUSION Currently, more than 2 years after her last pregnancy, the mother and all 5 babies are healthy and the mother's renal transplant function is normal.
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22
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Patient and Graft Outcomes Among Filipino Post-kidney Transplant Pregnancies. Transplant Proc 2019; 51:2718-2723. [PMID: 31477424 DOI: 10.1016/j.transproceed.2019.02.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/06/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Kidney transplantation (KT) has been shown to improve fertility rates among women post-transplant. However, despite the favorable outcome, the impact of pregnancy on the graft and the graft's effect on the fetus should be considered. In addition, these patients are exposed to anti-rejection medications that could affect the fetus. OBJECTIVE To describe the graft and pregnancy outcomes among KT recipients. METHODOLOGY Descriptive study of 32 post-KT recipients who were pregnant from January 1, 2001 to December 31, 2016 and were followed up 3 months post-partum. Each pregnancy was considered as an event. RESULTS Among the 32 post-KT patients there were 38 pregnancies. Mean age at conception was 34 years, with a mean interval between KT and pregnancy of 4.8 years. Around 84% took cyclosporine-based immunosuppression. The mean pre-natal serum creatinine was 1.15 mg/dL, 5.3% had ≥ 1.5 mg/dL pre-natal creatinine, and the rejection rate was 10.5%. The results of the pregnancies were as follows: 94% resulted in live births, 18.42% of mothers had pre-eclampsia, 3% had eclampsia, 3% ended in abortion, and 3% were stillbirth. Sixty-eight percent of the pregnancies were unplanned, and more complications were observed among these patients. CONCLUSION The maternal and fetal outcomes and complications in this study were comparable with other studies. However, most of these complications were observed with unplanned pregnancies. Counselling prior to pregnancy should therefore be emphasized.
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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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Aktürk S, Sadioğlu RE, Şengül Ş, Keven K. Acute kidney injury in an infant of a kidney allograft recipient. Clin Kidney J 2019; 13:123-124. [PMID: 32082563 PMCID: PMC7025340 DOI: 10.1093/ckj/sfz093] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 06/25/2019] [Indexed: 12/18/2022] Open
Abstract
Tacrolimus has been used in pregnant organ recipients for >20 years, and the relationship between fetal complications and the amount of tacrolimus crossing the placenta is still controversial. We report the case of a kidney transplant recipient who used tacrolimus and gave birth to an offspring that developed, shortly after birth, an acute kidney injury caused by tacrolimus exposure, which was detected by measuring tacrolimus levels in the umbilical vein, as well as in maternal blood. Even if whole‐blood levels of tacrolimus are within the therapeutic range throughout pregnancy, the amount of tacrolimus could reach toxic levels.
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Affiliation(s)
- Serkan Aktürk
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | | | - Şule Şengül
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Kenan Keven
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
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Al-Otaibi T, Gheith OA, Nagib AM, Nair P, Zakaria ZE, Halim MA, Said T, Abdelmonem M, Makkeyah Y, Aboatteya H, Elsawi IS, Atta AF. Pregnancy After Renal Transplant: Single Center Experience From the Middle East in Patients Using Different Calcineurin Inhibitors. EXP CLIN TRANSPLANT 2019; 17:99-104. [PMID: 30777531 DOI: 10.6002/ect.mesot2018.o42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Pregnancy after kidney transplant has a high risk for maternal and fetal complications; however, it can be successful if patients are properly selected. Here, we studied outcomes and complications of pregnancies in kidney transplant recipients who received calcineurin inhibitor-based immunosuppression. MATERIALS AND METHODS In this case control study, we reviewed patients who became pregnant between 2004 and 2017. For this analysis, each pregnancy was considered an event. We divided pregnancies into 2 groups according to calcineurin inhibitor-based maintenance immunosuppression: group 1 (49 pregnancies) received cyclosporine, and group 2 (33 pregnancies) received tacrolimus. Patients also received steroids and azathioprine. Patients had regular antenatal follow-up at the Hamed Alessa Organ Transplant Center (Kuwait) and in the maternity hospital (monthly until month 7 and then weekly until delivery). RESULTS Of 750 female kidney transplant recipients within childbearing potential, there were 82 pregnancies (10.9%) in 49 recipients (6.5%). Seventy-eight pregnancies were planned, and 4 pregnancies occurred while women were using contraception. There was 1 triple pregnancy, 5 double, and 76 single pregnancies. Two women had preeclampsia as maternal complication, 2 had uncontrolled hypertension, and 7 developed graft dysfunction. Forty-seven women (57.3%) had caesarean section, and the remaining had vaginal deliveries. Of 89 babies, 86 were viable (1 intrauterine fetal death and 2 abortions). Eight babies were delivered prematurely with low birth weight, and 2 needed incubators. Mean serum creatinine levels were 97.9 ± 24, 109 ± 38, 100 ± 39, 120 ± 46, and 115 ± 57 μmol/L at baseline, first, second, and third trimesters, and postpartum, respectively. Twelve patients showed high panel reactive antibodies but without donor-specific antibodies. CONCLUSIONS Posttransplant pregnancy can be successful in most renal allograft recipients, but the increased risk of fetal and maternal complications, including low birth weight, spontaneous abortus, and preeclampsia, should be considered.
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Affiliation(s)
- Torki Al-Otaibi
- From the Nephrology Department, Hamed Al-Essa Organ Transplant Center, Sabah Area, Kuwait
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Balaha M, Al-Otaibi T, Gheith OA, Halim MA, Shaker M, Fayyad Z, Nair P, Zakaria Z, Abo-Atya H, Makkeyia Y. Thymoglobulin-Resistant T-Cell-Mediated Acute Rejection in a Pregnant Renal Transplant Recipient: Case Report and Review of the Literature. EXP CLIN TRANSPLANT 2019; 17:159-163. [PMID: 30777545 DOI: 10.6002/ect.mesot2018.p38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
To avoid graft rejection during pregnancy, frequent monitoring of serum drug levels is recommended. Pregnancy induces hyperfiltration in transplanted kidneys, as in native kidneys; therefore, detection of rejection can be difficult when monitoring by serum creatinine. If rejection is suspected, ultrasonographguided graft biopsy can be done; once proven, it can be treated with pulse steroids, but data are scarce regarding other agents. Here, we present a 28-year-old pregnant female patient with resistant acute rejection but with successful pregnancy outcome. Our patient had end-stage kidney disease secondary to lupus nephropathy and underwent living-donor renal transplant in May 2013 after hemodialysis support for 1 year. She received thymoglobulin as induction therapy and was maintained on prednisolone, mycophenolate mofetil, and tacrolimus. She had normal renal graft function without proteinuria. After she received counseling, she became pregnant in February 2015. In June 2015, she presented with acute graft dysfunction with serum creatinine level of 365 μmol/L. Her abdominal ultrasonography showed mild hydronephrosis and viable fetus. She received empirical pulse steroids with partial response, and her graft biopsy showed acute T-cell-mediated rejection and negative C4d. Intravenous immunoglobulins and minipulse steroids were administered but without response. After gynecologic counseling and informed consent, she received 5 doses of thymoglobulin. She was dialysis dependent until premature vaginal labor, which resulted in birth of a viable 2-kg boy. We suggest that successful pregnancy outcomes could occur with close monitoring and daily dialysis in female kidney transplant patients with resistant rejection.
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Yaprak M, Doğru V, Sanhal CY, Özgür K, Erman M. In Vitro Fertilization After Renal Transplantation: A Single-Center Experience. Transplant Proc 2019; 51:1089-1092. [PMID: 31101177 DOI: 10.1016/j.transproceed.2019.01.105] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Although kidney transplantation often increases the chances of fertility, the rate of infertile patients is still high. In vitro fertilization promises successful results for infertile renal transplantation patients. The purpose of this study was to analyze the experience of a single center. METHODS Patients were invited to complete a survey for their obstetric history. Documentation review included demographic and clinical characteristics of patients, like procedure records, follow-up complications, immunosuppression maintenance protocols, and pregnancy outcomes. RESULTS Thirteen patients were reached to complete the survey. The mean age of patients was 33 ± 4 years at in vitro fertilization (IVF). The median duration of infertility was 2 years. Twenty-four IVF sessions were applied to these 13 women with renal transplantation. The procedure failed in 13 of these sessions; and 8 women achieved 11 clinical pregnancies. There were 3 miscarriages and 2 stillbirths. Six women had live births with no neonatal deaths. One patient had a graft rejection after the IVF procedure. Serum creatinine level increased more than 30% in 3 patients after the IVF procedure, while 9 patients had a minimal or no change. DISCUSSION In our study, we evaluated the records of 13 patients with renal transplantation who had IVF procedures. Fortunately, more than half of these patients had live births with no neonatal deaths. In our opinion, our findings show that IVF procedures can be accepted as a promising method in patients with renal transplantation and need a therapy for fertility. Moreover, a 25% live-birth rate per procedure is also a satisfactory result.
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Affiliation(s)
- M Yaprak
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey.
| | - V Doğru
- Department of General Surgery, Akdeniz University Hospital, Antalya, Turkey
| | - C Y Sanhal
- Department of Obstetrics and Gynecology, Akdeniz University Hospital, Antalya, Turkey
| | - K Özgür
- Antalya IVF, Antalya, Turkey
| | - M Erman
- Department of Obstetrics and Gynecology, Akdeniz University Hospital, Antalya, Turkey
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Sperm DNA Damage Before and After Kidney Transplantation. Nephrourol Mon 2019. [DOI: 10.5812/numonthly.86990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Shah S, Venkatesan RL, Gupta A, Sanghavi MK, Welge J, Johansen R, Kean EB, Kaur T, Gupta A, Grant TJ, Verma P. Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review. BMC Nephrol 2019; 20:24. [PMID: 30674290 PMCID: PMC6345071 DOI: 10.1186/s12882-019-1213-5] [Citation(s) in RCA: 106] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 01/15/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Reproductive function in women with end stage renal disease generally improves after kidney transplant. However, pregnancy remains challenging due to the risk of adverse clinical outcomes. METHODS We searched PubMed/MEDLINE, Elsevier EMBASE, Scopus, BIOSIS Previews, ISI Science Citation Index Expanded, and the Cochrane Central Register of Controlled Trials from date of inception through August 2017 for studies reporting pregnancy with kidney transplant. RESULTS Of 1343 unique studies, 87 met inclusion criteria, representing 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years. The live-birth rate was 72.9% (95% CI, 70.0-75.6). The rate of other pregnancy outcomes was as follows: induced abortions (12.4%; 95% CI, 10.4-14.7), miscarriages (15.4%; 95% CI, 13.8-17.2), stillbirths (5.1%; 95% CI, 4.0-6.5), ectopic pregnancies (2.4%; 95% CI, 1.5-3.7), preeclampsia (21.5%; 95% CI, 18.5-24.9), gestational diabetes (5.7%; 95% CI, 3.7-8.9), pregnancy induced hypertension (24.1%; 95% CI, 18.1-31.5), cesarean section (62.6, 95% CI 57.6-67.3), and preterm delivery was 43.1% (95% CI, 38.7-47.6). Mean gestational age was 34.9 weeks, and mean birth weight was 2470 g. The 2-3-year interval following kidney transplant had higher neonatal mortality, and lower rates of live births as compared to > 3 year, and < 2-year interval. The rate of spontaneous abortion was higher in women with mean maternal age < 25 years and > 35 years as compared to women aged 25-34 years. CONCLUSION Although the outcome of live births is favorable, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making.
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Affiliation(s)
- Silvi Shah
- Division of Nephrology Kidney C.A.R.E. Program, University of Cincinnati, 231 Albert Sabin Way, MSB 6112, Cincinnati, OH 45267 USA
| | | | - Ayank Gupta
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH USA
| | - Maitrik K. Sanghavi
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH USA
| | - Jeffrey Welge
- Health Sciences Library, College of Medicine, University of Cincinnati, Cincinnati, OH USA
| | - Richard Johansen
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH USA
| | - Emily B. Kean
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH USA
| | - Taranpreet Kaur
- Division of Nephrology Kidney C.A.R.E. Program, University of Cincinnati, 231 Albert Sabin Way, MSB 6112, Cincinnati, OH 45267 USA
| | - Anu Gupta
- Buffalo Medical Group, Buffalo, NY USA
| | - Tiffany J. Grant
- Department of Environmental Health, University of Cincinnati, Cincinnati, OH USA
| | - Prasoon Verma
- Division of Neonatology, Cincinnati Children’s Hospital and Medical Center, Cincinnati, OH USA
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Cabiddu G, Spotti D, Gernone G, Santoro D, Moroni G, Gregorini G, Giacchino F, Attini R, Limardo M, Gammaro L, Todros T, Piccoli GB. A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology. J Nephrol 2018; 31:665-681. [PMID: 29949013 PMCID: PMC6182355 DOI: 10.1007/s40620-018-0499-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/30/2018] [Indexed: 12/15/2022]
Abstract
Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".
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Affiliation(s)
| | | | | | | | | | | | | | | | - Monica Limardo
- Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | | | - Tullia Todros
- Department of Surgery, Università di Torino, Turin, Italy
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, Università di Torino, Turin, Italy.
- Centre Hospitalier Le Mans, Le Mans, France.
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Warzecha D, Szymusik I, Grzechocińska B, Cyganek A, Kociszewska-Najman B, Mazanowska N, Madej A, Pazik J, Wielgoś M, Pietrzak B. In Vitro Fertilization and Pregnancy Outcomes Among Patients After Kidney Transplantation: Case Series and Single-Center Experience. Transplant Proc 2018; 50:1892-1895. [DOI: 10.1016/j.transproceed.2018.02.144] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/19/2018] [Indexed: 11/15/2022]
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Abstract
PURPOSE OF REVIEW To review the studies and practice guidelines on the preeclampsia risks in kidney donors and recipients. RECENT FINDINGS There is a small increased risk of gestational hypertension and preeclampsia in pregnancies that follow kidney donation. Kidney Disease Improving Global Outcomes (KDIGO) Clinical Practice Guideline (2017) and the 2015 American Society of Transplantation (AST) consensus conference statement recommends counseling kidney donors about this increased risk. There is no observed increase in fetal complications or eclampsia post-kidney donation. Preeclampsia is more commonly observed in kidney transplant recipients than the general population and these patients should be co-managed with an obstetrician with experience in managing high risk pregnancies. Although preeclampsia has not been found to have a deleterious effect on renal graft function, it can cause premature delivery. Risk calculators have been proposed and an elevated pre-pregnancy creatinine seems to be an important risk. KDIGO Clinical Practice Guidelines (2009) recommends attempting pregnancy when kidney function is stable with proteinuria of less than 1 g per day. The use of novel biomarkers for preeclampsia has not been published in this population. Preeclampsia is an important concern for female kidney donors and recipients of child-bearing age. These individuals should be appropriately counseled.
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Affiliation(s)
- Pratik B Shah
- Section of Nephrology, University of Chicago Medicine, Chicago, IL, USA
| | - Manpreet Samra
- Division of Nephrology, University of Illinois at Chicago, Chicago, IL, USA
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Sarkar M, Bramham K, Moritz MJ, Coscia L. Reproductive health in women following abdominal organ transplant. Am J Transplant 2018; 18:1068-1076. [PMID: 29446243 PMCID: PMC5935794 DOI: 10.1111/ajt.14697] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/14/2018] [Accepted: 01/31/2018] [Indexed: 01/25/2023]
Abstract
Fertility is commonly impaired in women with end-stage kidney and liver disease, although most women will have restoration of fertility within 1 year of transplant. Family planning is therefore critical to discuss with reproductive-aged transplant recipients in the early posttransplant period, in order to ensure timely initiation of contraception, and optimal timing for conception. For women seeking pregnancy, the risks to the mother, graft, and baby should be discussed, including evaluation of immunosuppression safety and potential for adjusting medications prior to conception. With an increasing number of transplant patients now breastfeeding, immunosuppression safety in lactation continues to carry great importance.
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Affiliation(s)
- Monika Sarkar
- Department of Medicine, Division of Gastroenterology and Hepatology, University of California, San Francisco, San Francisco, CA, USA
| | - Kate Bramham
- Department of Renal Medicine, Division of Transplantation and Mucosal Biology, King’s College London, London, UK
| | - Michael J. Moritz
- Gift of Life Institute, Transplant Pregnancy Registry (TPR) International, Philadelphia, PA, USA,Lehigh Valley Health Network, Allentown, PA, USA,University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Lisa Coscia
- Gift of Life Institute, Transplant Pregnancy Registry (TPR) International, Philadelphia, PA, USA
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Hormone therapy and clinical and surrogate cardiovascular endpoints in women with chronic kidney disease: a systematic review and meta-analysis. Menopause 2018; 23:1028-37. [PMID: 27433866 DOI: 10.1097/gme.0000000000000657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Women with chronic kidney disease (CKD) experience kidney dysfunction-mediated premature menopause. The role of postmenopausal hormone therapy (HT) in this population is unclear. We sought to summarize current knowledge regarding use of postmenopausal HT and cardiovascular (CV) outcomes, and established surrogate measures of CV risk in women with CKD. METHODS This is a systematic review and meta-analysis of adult women with CKD. We searched electronic bibliographic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials) (inception to 2014 December), relevant conference proceedings, tables of contents of journals, and review articles. Randomized controlled trials and observational studies examining postmenopausal HT compared with either placebo or untreated control groups were included. The intervention of interest was postmenopausal HT, and the outcome measures were all-cause and CV mortality, nonfatal CV event (myocardial infarction, stroke), and surrogate measures of CV risk (serum lipids, blood pressure). RESULTS Of 12,482 references retrieved, four randomized controlled trials and two cohort studies (N = 1,666 participants) were identified. No studies reported on CV outcomes or mortality. Compared with placebo, postmenopausal HT was associated with decreased low-density lipoprotein cholesterol (-13.2 mg/dL [95% CI, -23.32 to -3.00 mg/dL]), and increased high-density lipoprotein (8.73 mg/dL [95% CI, 4.72-12.73 mg/dL]) and total cholesterol (7.96 mg/dL [95% CI, 0.07-15.84 mg/dL]). No associations were observed between postmenopausal HT triglyceride levels and blood pressure. CONCLUSIONS Studies examining the effect of postmenopausal HT on CV outcomes in women with CKD are lacking. Further prospective study of the role of postmenopausal HT in this high-risk group is required.
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Stoumpos S, Lees J, Welsh P, Hund M, Geddes CC, Nelson SM, Mark PB. The utility of anti-Müllerian hormone in women with chronic kidney disease, on haemodialysis and after kidney transplantation. Reprod Biomed Online 2017; 36:219-226. [PMID: 29233504 DOI: 10.1016/j.rbmo.2017.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 11/15/2017] [Accepted: 11/15/2017] [Indexed: 11/19/2022]
Abstract
Women with renal disease have menstrual and gonadal dysfunction manifesting as hormonal imbalance. Anti-Müllerian hormone (AMH) is a potential measure of ovarian reserve. We examined circulating AMH concentrations in young women with renal failure, determined associations with clinical characteristics, and compared AMH with age-matched healthy individuals. AMH was measured in 77 women: 26 had chronic kidney disease (CKD), 26 were on haemodialysis (HD), and 25 had a kidney transplant. Random AMH levels were highest in women on HD [HD 2.9 (1.1-5.2), CKD 1.6 (0.7-2.2), transplant 1.5 (1.0-4.2) ng/ml]. On multiple linear regression, AMH was 53% higher [95% CI 0.20-0.98, P = 0.002] in women on HD and decreased by 20% per 5-year increase in age (P < 0.001). AMH was 43% lower in women with renal failure compared with 600 age-matched controls [1.7 (0.9-3.8) versus 3.0 (1.9-5.0) ng/ml, P < 0.001]; however, we found no difference in AMH between those on HD and healthy individuals [2.9 (1.1-5.2) versus 3.0 (1.9-5.0) ng/ml]. AMH may be a useful biomarker in female renal patients with non-dialysis dependent renal disease pursuing pregnancy. In contrast, AMH levels are higher in HD but unlikely to reflect ovarian reserve.
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Affiliation(s)
- Sokratis Stoumpos
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Cardiovascular and Medical Sciences, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - Jennifer Lees
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Cardiovascular and Medical Sciences, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Paul Welsh
- Institute of Cardiovascular and Medical Sciences, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Martin Hund
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - Colin C Geddes
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Patrick B Mark
- The Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK; Institute of Cardiovascular and Medical Sciences, Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Moaveni DM, Cohn JH, Hoctor KG, Longman RE, Ranasinghe JS. Anesthetic Considerations for the Parturient After Solid Organ Transplantation. Anesth Analg 2017; 123:402-10. [PMID: 27285002 DOI: 10.1213/ane.0000000000001391] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the past 40 years, the success of organ transplantation has increased such that female solid organ transplant recipients are able to conceive and carry pregnancies successfully to term. Anesthesiologists are faced with the challenge of providing anesthesia care to these high-risk obstetric patients in the peripartum period. Anesthetic considerations include the effects of the physiologic changes of pregnancy on the transplanted organ, graft function in the peripartum period, and the maternal side effects and drug interactions of immunosuppressive agents. These women are at an increased risk of comorbidities and obstetric complications. Anesthetic management should consider the important task of protecting graft function. Optimal care of a woman with a transplanted solid organ involves management by a multidisciplinary team. In this focused review article, we review the anesthetic management of pregnant patients with solid organ transplants of the kidney, liver, heart, or lung.
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Affiliation(s)
- Daria M Moaveni
- From the Departments of *Clinical Anesthesiology and †Obstetrics and Gynecology, University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, Florida
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Majak GB, Reisæter AV, Zucknick M, Lorentzen B, Vangen S, Henriksen T, Michelsen TM. Preeclampsia in kidney transplanted women; Outcomes and a simple prognostic risk score system. PLoS One 2017; 12:e0173420. [PMID: 28319175 PMCID: PMC5358770 DOI: 10.1371/journal.pone.0173420] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 02/19/2017] [Indexed: 01/30/2023] Open
Abstract
Women pregnant following kidney transplantation are at high risk of preeclampsia. Identifying the effects of preeclampsia on pregnancy outcome and allograft function in kidney transplanted women, and predicting which women will require more targeted follow-up and possible therapeutic intervention, could improve both maternal and neonatal outcome. In this retrospective cohort study of all pregnancies following kidney transplantation in Norway between 1969 and 2013, we used medical records to identify clinical characteristics predictive of preeclampsia. 175 pregnancies were included, in which preeclampsia was diagnosed in 65. Pregnancies with preeclampsia had significantly higher postpartum serum creatinine levels, higher risks of preterm delivery, caesarean delivery, and small for gestational age infants. In the final multivariate model chronic hypertension (aOR = 5.02 [95% CI, 2.47–10.18]), previous preeclampsia (aOR = 3.26 [95% CI, 1.43–7.43]), and elevated serum creatinine (≥125 μmol/L) at the start of pregnancy (aOR = 5.79 [95% CI, 1.91–17.59]) were prognostic factors for preeclampsia. Based on this model the risk was 19% when none of these factors were present, 45–59% risk when one was present, 80–87% risk when two were present, and 96% risk when all three were present. We suggest that the risk of preeclampsia in pregnancies in kidney transplanted women can be predicted with these variables, which are easily available at the start of pregnancy.
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Affiliation(s)
- Guri Baardstu Majak
- Department of Obstetrics, Division of Gynecology and Obstetrics, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Norwegian National Advisory Unit on Women´s Health, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- * E-mail:
| | - Anna Varberg Reisæter
- The Norwegian Renal Registry, Department of Transplantation Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Manuela Zucknick
- Oslo Centre for Biostatistics and Epidemiology, Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Bjørg Lorentzen
- Department of Obstetrics, Division of Gynecology and Obstetrics, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Siri Vangen
- Norwegian National Advisory Unit on Women´s Health, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Tore Henriksen
- Department of Obstetrics, Division of Gynecology and Obstetrics, Oslo University Hospital Rikshospitalet, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Trond Melbye Michelsen
- Department of Obstetrics, Division of Gynecology and Obstetrics, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Norwegian National Advisory Unit on Women´s Health, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Research Unit, Sørlandet Hospital, Arendal, Norway
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Madaan A, Nadeau-Vallée M, Rivera JC, Obari D, Hou X, Sierra EM, Girard S, Olson DM, Chemtob S. Lactate produced during labor modulates uterine inflammation via GPR81 (HCA 1). Am J Obstet Gynecol 2017; 216:60.e1-60.e17. [PMID: 27615440 DOI: 10.1016/j.ajog.2016.09.072] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/18/2016] [Accepted: 09/01/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Uterine inflammatory processes trigger prolabor pathways and orchestrate on-time labor onset. Although essential for successful labor, inflammation needs to be regulated to avoid uncontrolled amplification and resolve postpartum. During labor, myometrial smooth muscle cells generate ATP mainly via anaerobic glycolysis, resulting in accumulation of lactate. Aside from its metabolic function, lactate has been shown to activate a G protein-coupled receptor, GPR81, reported to regulate inflammation. We therefore hypothesize that lactate produced during labor may act via GPR81 in the uterus to exert in a feedback manner antiinflammatory effects, to resolve or mitigate inflammation. OBJECTIVE We sought to investigate the role of lactate produced during labor and its receptor, GPR81, in regulating inflammation in the uterus. STUDY DESIGN We investigated the expression of GPR81 in the uterus and the pharmacological role of lactate acting via GPR81 during labor, using shRNA-GPR81 and GPR81-/- mice. RESULTS (1) Uterine lactate levels increased substantially from 2 to 9 mmol/L during labor. (2) Immunohistological analysis revealed expression of GPR81 in the uterus with high expression in myometrium. (3) GPR81 expression increased during gestation, and peaked near labor. (4) In primary myometrial smooth muscle cell and ex vivo uteri from wild-type mice, lactate decreased interleukin-1β-induced transcription of key proinflammatory Il1b, Il6, Ccl2, and Pghs2; suppressive effects of lactate were not observed in cells and tissues from GPR81-/- mice. (5) Conversely, proinflammatory gene expression was augmented in the uterus at term in GPR81-/- mice and wild-type mice treated intrauterine with lentiviral-encoded shRNA-GPR81; GPR81 silencing also induced proinflammatory gene transcription in the uterus when labor was induced by endotoxin (lipopolysaccharide). (6) Importantly, administration to pregnant mice of a metabolically stable specific GPR81 agonist, 3,5-dihydroxybenzoic acid, decreased endotoxin-induced uterine inflammation, preterm birth, and associated neonatal mortality. CONCLUSION Collectively, our data uncover a novel link between the anaerobic glycolysis and the control of uterine inflammation wherein the high levels of lactate produced during labor act on uterine GPR81 to down-regulate key proinflammatory genes. This discovery may represent a novel feedback mechanism to regulate inflammation during labor, and conveys a potential rationale for the use of GPR81 agonists to attenuate inflammation and resulting preterm birth.
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Orihuela S, Nin M, San Román S, Noboa O, Curi L, Silvariño R, González-Martínez F. Successful Pregnancies in Kidney Transplant Recipients: Experience of the National Kidney Transplant Program From Uruguay. Transplant Proc 2016; 48:643-5. [PMID: 27110021 DOI: 10.1016/j.transproceed.2016.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Renal transplantation increases the possibilities of pregnancy in women of reproductive age. The course of pregnancy was analyzed retrospectively in patients with kidney or kidney-pancreas transplant, surveying maternal-fetal or renal graft complications and the relation with pre-pregnancy renal function. METHODS A cohort that includes all the kidney transplant recipients who went through pregnancy in Uruguay in a period of 28 years is described. Forty pregnancies in 32 patients were registered; the average time between the kidney transplant and the beginning of the gestation period was 47 months. From the total gestations, 10 abortions, 1 neonatal death, and 1 fetal demise were registered. From the remaining pregnancies, we highlight prematurity (18/29) and low birth weight (14/21). Twenty-nine in 30 pregnancies ended in cesarean section; in 8 of 30, pre-eclampsia diagnosis was performed. Acute rejection was diagnosed in 2 of 30 pregnancies, both undergoing their first post-transplant year. RESULTS Two patients required dialysis throughout the pregnancy because of progress into severe renal insufficiency. Higher obstetric perinatal morbidity and renal function deterioration was related to lower pre-pregnancy glomerular filtration rate (GFR). CONCLUSIONS A successful pregnancy is possible in transplant recipients, yet there are risks of prematurity, low birth weight, and abortion. A lower GFR before pregnancy was associated with poorer maternal and perinatal results as shown in the different series.
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Affiliation(s)
- S Orihuela
- Nephrology and Urology Institute, Montevideo, Uruguay
| | - M Nin
- Nephrology and Urology Institute, Montevideo, Uruguay; Department of Nephrology, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay.
| | - S San Román
- Department of Nephrology, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - O Noboa
- Department of Nephrology, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - L Curi
- Nephrology and Urology Institute, Montevideo, Uruguay
| | - R Silvariño
- Department of Nephrology, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - F González-Martínez
- Nephrology and Urology Institute, Montevideo, Uruguay; Department of Nephrology, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
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Overview of Pregnancy in Renal Transplant Patients. Int J Nephrol 2016; 2016:4539342. [PMID: 28042483 PMCID: PMC5155089 DOI: 10.1155/2016/4539342] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/05/2016] [Accepted: 11/09/2016] [Indexed: 12/25/2022] Open
Abstract
Kidney transplantation offers best hope to women with end-stage renal disease who wish to become pregnant. Pregnancy in a kidney transplant recipient continues to remain challenging due to side effects of immunosuppressive medication, risk of deterioration of allograft function, risk of adverse maternal complications of preeclampsia and hypertension, and risk of adverse fetal outcomes of premature birth, low birth weight, and small for gestational age infants. The factors associated with poor pregnancy outcomes include presence of hypertension, serum creatinine greater than 1.4 mg/dL, and proteinuria. The recommended maintenance immunosuppression in pregnant women is calcineurin inhibitors (tacrolimus/cyclosporine), azathioprine, and low dose prednisone; and it is considered safe. Sirolimus and mycophenolate mofetil should be stopped 6 weeks prior to conception. The optimal time to conception continues to remain an area of contention. It is important that counseling for childbearing should start as early as prior to getting a kidney transplant and should be done at every clinic visit after transplant. Breast-feeding is not contraindicated and should not be discouraged. This review will help the physicians in medical optimization and counseling of renal transplant recipients of childbearing age.
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Parajuli S, Clark DF, Djamali A. Is Kidney Transplantation a Better State of CKD? Impact on Diagnosis and Management. Adv Chronic Kidney Dis 2016; 23:287-294. [PMID: 27742382 DOI: 10.1053/j.ackd.2016.09.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Patients with CKD are at increased risk for cardiovascular events, hospitalizations, and mortality. Kidney transplantation (KTx) is the preferred treatment for end-stage kidney disease. Although comorbidities including anemia and bone and mineral disease improve or are even halted after KTx, kidney transplant recipients carry higher cardiovascular mortality risk than the general population, as well as an increased risk of infections, malignancies, fractures, and obesity. When comparing CKD with CKD after transplantation (CKD-T), the rate of decline of estimated glomerular filtration rate (eGFR) is significantly lower in CKD-T. Higher rate of decline of eGFR has been associated with increased risk of mortality. However, due to the significant increased risk of mortality due to cardiovascular events, infections, and malignancies, many kidney transplant recipients may not benefit of decline in the rate of eGFR. Patients with CKD-T are a unique subset of patients with multiple traditional and transplant-specific risk factors. Proper management and appropriate preventive health measures may improve long-term patient and allograft survival in patients with CKD-T.
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Wielgos M, Pietrzak B, Mazanowska N, Kociszewska-Najman B. Neonates of mothers who have had kidney or liver transplantation. J Perinat Med 2016; 44:691-4. [PMID: 27049614 DOI: 10.1515/jpm-2016-0020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Rose C, Gill J, Zalunardo N, Johnston O, Mehrotra A, Gill JS. Timing of Pregnancy After Kidney Transplantation and Risk of Allograft Failure. Am J Transplant 2016; 16:2360-7. [PMID: 26946063 DOI: 10.1111/ajt.13773] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 02/12/2016] [Accepted: 02/12/2016] [Indexed: 01/25/2023]
Abstract
The optimal timing of pregnancy after kidney transplantation remains uncertain. We determined the risk of allograft failure among women who became pregnant within the first 3 posttransplant years. Among 21 814 women aged 15-45 years who received a first kidney-only transplant between 1990 and 2010 captured in the United States Renal Data System, n = 729 pregnancies were identified using Medicare claims. The probability of allograft failure from any cause including death (ACGL) at 1, 3, and 5 years after pregnancy was 9.6%, 25.9%, and 36.6%. In multivariate analyses, pregnancy in the first posttransplant year was associated with an increased risk of ACGL (hazard ratio [HR]: 1.18; 95% confidence interval [CI] 1.00, 1.40) and death censored graft loss (DCGL) (HR:1.25; 95% CI 1.04, 1.50), while pregnancy in the second posttransplant year was associated with an increased risk of DCGL (HR: 1.26; 95% CI 1.06, 1.50). Pregnancy in the third posttransplant year was not associated with an increased risk of ACGL or DCGL. These findings demonstrate a higher incidence of allograft failure after pregnancy than previously reported and that the increased risk of allograft failure extends to pregnancies in the second posttransplant year.
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Affiliation(s)
- C Rose
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada
| | - N Zalunardo
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - O Johnston
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - A Mehrotra
- Division of Nephrology, Mount Sinai School of Medicine, New York, NY
| | - J S Gill
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcomes Sciences, University of British Columbia, Vancouver, Canada.,Tufts-New England Medical Center, Boston, MA
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Kociszewska-Najman B, Pietrzak B, Czaplinska N, Cyganek A, Jabiry-Zieniewicz Z, Schreiber-Zamora J, Drozdowska-Szymczak A, Bobrowska K, Wielgos M. Congenital Infections in Neonates of Women With Liver or Kidney Transplants. Transplant Proc 2016; 48:1556-60. [DOI: 10.1016/j.transproceed.2016.01.088] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/21/2016] [Indexed: 10/21/2022]
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45
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Tsao CI, Chou NK, Chi NH, Huang SC, Tsan CY, Wang CH, Yu HY, Wu IH, Chen YS, Shun CT, Wang SS. Surveillance of Immunosuppression During Pregnancy After Heart Transplantation: Case Report. Transplant Proc 2016; 48:978-81. [PMID: 27234783 DOI: 10.1016/j.transproceed.2016.02.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 01/27/2016] [Accepted: 02/18/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Transplantation and immunosuppressive drugs are major limitations to the success of pregnancy. In 1988, the first pregnancy after a heart transplant was reported, which has given female recipients the hope to give birth. During pregnancy, physiologic changes with increased blood volume and hemodilution may influence blood drug level. CASE REPORT We reported our experience in monitoring on immunosuppressive drugs for 2 cases. Both of them underwent heart transplantation in 2006 and were 34 and 37 years old at time of pregnancy. For both cases, we frequently monitored the blood level and increased the dosage of immunosuppressive drugs accordingly. Both cases had uneventful pregnancy and delivery to healthy babies at the National Taiwan University Hospital in Taiwan. Their postpartum courses were uneventful as well. CONCLUSIONS We advocate adjusting the immunosuppressive dosage according to the blood level before pregnancy.
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Affiliation(s)
- C-I Tsao
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - N-K Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N-H Chi
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - S-C Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-Y Tsan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - H-Y Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-H Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Y-S Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-T Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - S-S Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Department of Surgery, Fu Jen Catholic University Hospital, and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan.
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Rao S, Ghanta M, Moritz MJ, Constantinescu S. Long-Term Functional Recovery, Quality of Life, and Pregnancy After Solid Organ Transplantation. Med Clin North Am 2016; 100:613-29. [PMID: 27095649 DOI: 10.1016/j.mcna.2016.01.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article reviews the salient features of functional recovery, health-related quality of life (HR-QOL), and reproductive health, with special emphasis on pregnancy outcomes in kidney and liver recipients. Transplantation results in improved functional status and HR-QOL. Addressing factors that limit the optimal rehabilitation of transplant recipients can improve transplant outcomes. After successful transplantation, there is a rapid return of fertility, warranting counseling regarding contraception. Practitioners should be aware of the teratogenic potential of mycophenolic acid products. Posttransplant pregnancies are high risk, with increased incidences of hypertension, preeclampsia, and prematurity. Most pregnancies in kidney and liver recipients have successful maternal and newborn outcomes.
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Affiliation(s)
- Swati Rao
- Section of Nephrology, Hypertension and Kidney Transplantation, Temple University School of Medicine, 3440 North Broad Street, Kresge West, Suite 100, Philadelphia, PA 19140, USA
| | - Mythili Ghanta
- Pancreas Transplant Program, Section of Nephrology, Hypertension and Kidney Transplantation, Temple University School of Medicine, 3440 North Broad Street, Kresge West, Suite 100, Philadelphia, PA 19140, USA
| | - Michael J Moritz
- Transplant Services, Lehigh Valley Health Network, Allentown, PA 18103, USA; Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA; National Transplantation Pregnancy Registry, Gift of Life Institute, 401 North 3rd Street, Philadelphia, PA 19123, USA
| | - Serban Constantinescu
- National Transplantation Pregnancy Registry, Gift of Life Institute, 401 North 3rd Street, Philadelphia, PA 19123, USA; Kidney Transplant Program, Section of Nephrology, Hypertension and Kidney Transplantation, Temple University School of Medicine, 3440 North Broad Street, Kresge West, Suite 100, Philadelphia, PA 19140, USA.
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Kutzler HL, Ye X, Rochon C, Martin ST. Administration of Antithymocyte Globulin (Rabbit) to Treat a Severe, Mixed Rejection Episode in a Pregnant Renal Transplant Recipient. Pharmacotherapy 2016; 36:e18-22. [DOI: 10.1002/phar.1725] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Xiaoyi Ye
- Department of Medicine; Hartford Hospital; Hartford Connecticut
- Department of Transplant; Hartford Hospital; Hartford Connecticut
| | - Caroline Rochon
- Department of Transplant; Hartford Hospital; Hartford Connecticut
- Department of Surgery; Hartford Hospital; Hartford Connecticut
| | - Spencer T. Martin
- Department of Transplant; Hartford Hospital; Hartford Connecticut
- Department of Pharmacy Services; Hartford Hospital; Hartford Connecticut
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48
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Yousif MEA, Bridson JM, Halawa A. Contraception After Kidney Transplantation, From Myth to Reality: A Comprehensive Review of the Current Evidence. EXP CLIN TRANSPLANT 2016; 14:252-8. [PMID: 27041141 DOI: 10.6002/ect.2015.0278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is a misconception among transplant clinicians that contraception after a successful renal transplant is challenging. This is partly due to the complex nature of transplant patients, where immunosuppression and graft dysfunction create major concerns. In addition, good evidence regarding contraception and transplant is scarce, with most of the evidence extrapolated from observational and case-controlled studies, thus adding to the dilemma of treating these patients. In this review, we closely analyzed the different methods of contraception and critically evaluated the efficacy of the different options for contraception after kidney transplant. We conclude that contraception after renal transplant is successful with acceptable risk. A multidisciplinary team approach involving obstetricians and transplant clinicians to decide the appropriate timing for conception is recommended. Early counseling on contraception is important to reduce the risk of unplanned pregnancies, improve pregnancy outcomes, and reduce maternal complications in patients after kidney transplant. To ascertain appropriate advice on the method of contraception, individualizing the method of contraception according to a patient's individual risks and expectations is essential.
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Affiliation(s)
- Mohamed Elamin Awad Yousif
- From the Nephrology Unit, Ibn Sina Hospital, Khartoum, Sudan; and the Faculty of Health and Science, Institute of Learning and Teaching, University of Liverpool, Liverpool, UK
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49
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Kovács DÁ, Szabó L, Jenei K, Fedor R, Zádori G, Zsom L, Kabai K, Záhonyi A, Asztalos L, Nemes B. Pregnancy management of women with kidney transplantation. Interv Med Appl Sci 2016; 7:161-5. [PMID: 26767122 DOI: 10.1556/1646.7.2015.4.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Women with renal disease, besides many dysfunctions, face increasing infertility and high-risk pregnancy due to uremia and changes of the hormonal functions. After renal transplantation, sexual dysfunction improves, providing the possibility of successful pregnancy for women of childbearing age. However, kidney transplanted patients are high-risk pregnant patients with increased maternal and fetal risks, and the graft also may be compromised during pregnancy; most studies report on several successive deliveries due to multidisciplinary team management. In clinical practice, the graft is rarely affected during the period of gestation. Fetal development disorders are also rare although preterm delivery and intrauterine growth retardation are common. For now, several studies and clinical investigations proved that, under multidisciplinary control, kidney transplanted female patients are also possible to have safe pregnancy and successful delivery. There are conflicting data in the literature about the prevention of complications and the timing of pregnancy. Herein, we would like to present some experience of our centre. A total of 847 kidney transplantations have been performed between June 1993 and December 2013 with 163 childbearing aged females (18-45 years) in our center. We report on three kidney transplanted patients who have given birth to healthy newborns. In our practice, severe complications have not been observed.
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Affiliation(s)
| | - László Szabó
- Institute of Surgery, University of Debrecen , Debrecen , Hungary
| | - Katalin Jenei
- Institute of Obstetrics and Gynecology, University of Debrecen , Debrecen , Hungary
| | - Roland Fedor
- Institute of Surgery, University of Debrecen , Debrecen , Hungary
| | - Gergely Zádori
- Institute of Surgery, University of Debrecen , Debrecen , Hungary
| | - Lajos Zsom
- Institute of Surgery, University of Debrecen , Debrecen , Hungary
| | - Krisztina Kabai
- Institute of Surgery, University of Debrecen , Debrecen , Hungary
| | - Anita Záhonyi
- Institute of Surgery, University of Debrecen , Debrecen , Hungary
| | - László Asztalos
- Institute of Surgery, University of Debrecen , Debrecen , Hungary
| | - Balázs Nemes
- Institute of Surgery, University of Debrecen , Debrecen , Hungary
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50
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Knickelbein JE, Armbrust KR, Kim M, Sen HN, Nussenblatt RB. Pharmacologic Treatment of Noninfectious Uveitis. Handb Exp Pharmacol 2016; 242:231-268. [PMID: 27848029 DOI: 10.1007/164_2016_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Uveitis encompasses a spectrum of diseases whose common feature is intraocular inflammation, which may be infectious or noninfectious in etiology (Nussenblatt and Whitcup 2010). Infectious causes of uveitis are typically treated with appropriate antimicrobial therapy and will not be discussed in this chapter. Noninfectious uveitides are thought have an autoimmune component to their etiology and are thus treated with anti-inflammatory agents.
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Affiliation(s)
- Jared E Knickelbein
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Karen R Armbrust
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Meredith Kim
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA
| | - H Nida Sen
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA
| | - Robert B Nussenblatt
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bldg 10 Room 10N109, 10 Center Drive, Bethesda, MD, 20892, USA.
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