Twin pregnancy after kidney transplantation: what's on? A case report and review of literature

Maternal Renal Dysfunction in Late Pregnancy in Twin and Singleton Pregnancies: Retrospective Study

This study aimed to evaluate the differences in the impact on maternal renal function between singleton and twin pregnancies in the second half of pregnancy. It retrospectively enrolled 1711 pregnant women consisting of 1547 singleton pregnancies and 164 twin pregnancies from Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital from January 2019 to June 2021. Patients underwent renal function tests (serum blood urea nitrogen, creatinine, and estimated glomerular filtration rate (eGFR)) at least one month before delivery. The main outcome measure was maternal renal dysfunction, defined as a serum creatinine level above 0.8 mg/dL. The serum creatinine level was significantly higher and the eGFR was significantly lower in twin than in singleton pregnancies (p < 0.001). In addition, the rate of renal dysfunction was significantly higher in twin than in singleton pregnancies (7.9% vs. 2.6%; p < 0.01). Multivariate analysis revealed that twin pregnancy (odds ratio (OR) 3.38), nulliparity (OR 2.31), and preeclampsia (OR 3.64) were significant risk factors for maternal renal dysfunction. Maternal renal dysfunction was observed in 13 twin pregnancies, all of which recovered to within normal limits during the early months of the postpartum period. Twin pregnancy is a significant risk factor for maternal renal dysfunction; renal function should be carefully monitored in twin pregnancies.

Twin pregnancy after kidney transplantation: case report and systematic review

BACKGROUND

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

CASE

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

DISCUSSION AND CONCLUSION

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

Consecutive Spontaneous Triplet and Twin Pregnancies in a Woman After Renal Transplantation

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.

Successful management of twin pregnancy in a woman with advanced chronic kidney disease: A case report

RATIONALE

Twin pregnancy in women with chronic kidney disease (CKD) is very rare but poses a great risk to both mother and children. In developing countries like China, advanced CKD twin pregnancies are often terminated. Here, we report a successful case and reviewed related cases, hope to facilitate further study.

PATIENT CONCERNS

A 29-year-old woman with a twin pregnancy showed serum creatinine (Scr) 100 μmol/L (CKD2) at conception. During her 12th week, Scr reached 263 μmol/L (CKD4) with urine protein 3+ and hypertension.

DIAGNOSES

Due to her pregnancy, renal biopsy was not considered. Lab tests showed deterioration of renal function and ultrasound detections showed small kidney size.

INTERVENTIONS

The patient was given basic drug therapy to control her blood pressure and supplemental nutrition without hemodialysis.

OUTCOMES

The patient delivered 2 healthy babies weighting 0.9 and 0.7 kg by cesarean section at the 28th week, but has been under maintenance hemodialysis since then.

LESSONS

Despite low birth weight and preterm delivery, successful twin pregnancies in some patients with CKD could be realized under early multidisciplinary intervention, but this poses great risks for mothers and twins, especially for patients with advanced CKD and those on hemodialysis.

Acute Kidney Injury in Pregnant Patient With Pancreas-Kidney Transplant Caused by Abdominal Compartment Syndrome: A Case Presentation, Review of Literature, and Proposal of Diagnostic Approach

Rationale:

With increasing number of complex medical patients with renal transplant who get pregnant, clinicians need to be aware of abdominal compartment syndrome which may masquerade as acute renal allograft injury in pregnancy.

Presenting concerns of the patient:

A 34-year-old nulliparous Caucasian female with end-stage renal disease (ESRD) due to type 1 diabetes mellitus who received a simultaneous pancreas-kidney transplant (SPK) in 2006 and then after rejection of renal allograft another, kidney-only allograft from a donation after circulatory death became pregnant in May 2013 with dichorionic, diamniotic twins without reproductive technology, and during pregnancy, she developed two episodes of acute injury to the renal allograft.

Diagnoses:

End-stage renal disease secondary to type I diabetes, acute renal allograft injury, tacrolimus toxicity, abdominal pain.

Interventions (including prevention and lifestyle):

She received intravenous hydration, medications contributing to renal failure were held, and pain and nauseas were controlled appropriately. Abdominal compartment syndrome was managed by maintaining intravascular pressure and optimizing regional and systemic vascular perfusion by appropriate fluid balance, evacuating intraluminal contents by decompressing gastrointestinal system, and improving abdominal wall compliance by using appropriate analgesics, sedation, and patient positioning.

Outcomes:

With advancing pregnancy, the patient developed progressive abdominal pain, nausea, leg edema, and rising creatinine that were not responsive to ongoing therapies and required delivery via Cesarean section at 31 weeks of gestational age.

Lessons learned:

In the era of increasing number of pregnant renal transplant patients with multiple medical issues, we need organized approach to diagnosis of acute renal allograft injury in pregnancy and we need to consider abdominal compartment syndrome as one of the causes.

Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases

Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.