Congenital Infections in Neonates of Women With Liver or Kidney Transplants

Genetic Screening and Teratogenic Exposures: Considerations in Caring for the Uterus Transplant Patient

Counseling the uterus transplant patient requires an enhanced knowledge of unique genetic challenges that include an understanding of the spectrum of Mayer-Rokitansky-Küster-Hauser syndrome. Patients should understand their options for genetic screening and testing including preimplantation genetic testing for aneuploidy, genetic screening, and diagnostic testing. This patient population is potentially at risk for fetal anomalies due to the increased susceptibility to infections, such as cytomegalovirus. There are management strategies to minimize this risk. The risk of teratogenicity from mycophenolate is eliminated by a washout period before embryo transfer.

Usage of Tacrolimus and Mycophenolic Acid During Conception, Pregnancy, and Lactation, and Its Implications for Therapeutic Drug Monitoring: A Systematic Critical Review

BACKGROUND

Conception, pregnancy, and lactation following solid organ transplantation require appropriate management. The most frequently used immunosuppressive drug combination after solid organ transplantation consists of tacrolimus (Tac) plus mycophenolic acid (MPA). Here, the effects of Tac and MPA on fertility, pregnancy, and lactation are systematically reviewed, and their implications for therapeutic drug monitoring (TDM) are discussed.

METHODS

A systematic literature search was performed (August 19, 2019) using Ovid MEDLINE, EMBASE, the Cochrane Central Register of controlled trials, Google Scholar, and Web of Science, and 102 studies were included. Another 60 were included from the reference list of the published articles.

RESULTS

As MPA is teratogenic, women who are trying to conceive are strongly recommended to switch from MPA to azathioprine. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes. Nevertheless, in 2015, the drug label was updated with additional risk minimization measures in a pregnancy prevention program. Data on MPA pharmacokinetics during pregnancy and lactation are limited. Tac treatment during conception, pregnancy, and lactation seems to be safe in terms of the health of the mother, (unborn) child, and allograft. However, Tac may increase the risk of hypertension, preeclampsia, preterm birth, and low birth weight. Infants will ingest very small amounts of Tac via breast milk from mothers treated with Tac. However, no adverse outcomes have been reported in children exposed to Tac during lactation. During pregnancy, changes in Tac pharmacokinetics result in increased unbound to whole-blood Tac concentration ratio. To maintain Tac concentrations within the target range, increased Tac dose and intensified TDM may be required. However, it is unclear if dose adjustments during pregnancy are necessary, considering the higher concentration of (active) unbound Tac.

CONCLUSIONS

Tac treatment during conception, pregnancy and lactation seems to be relatively safe. Due to pharmacokinetic changes during pregnancy, a higher Tac dose might be indicated to maintain target concentrations. However, more evidence is needed to make recommendations on both Tac dose adjustments and alternative matrices than whole-blood for TDM of Tac during pregnancy. MPA treatment in men during conception seems to have no adverse effect on pregnancy outcomes, whereas MPA use in women during conception and pregnancy is strongly discouraged.

Female reproductive health in cystic fibrosis

Women with cystic fibrosis (CF) are living longer and healthier lives, and opportunities for childbearing are increasingly promising. However, this population can also face sexual and reproductive health concerns, including menstrual irregularities, unplanned pregnancies, infertility and pregnancy complications. Additionally, more women are entering menopause and are at risk for the consequences of estrogen deficiency. The exact mechanisms involved in female reproductive health conditions in CF are not clearly understood, but are thought to include cystic fibrosis transmembrane regulator (CFTR)-mediated abnormalities, changes in female sex hormones, and other CF health-related factors. In the era of CFTR modulator therapy, new data are necessary to understand the impact of CFTR modulation on contraceptive effectiveness, fertility, and pregnancy outcomes to help guide future clinical care. This article reviews the current scientific knowledge of major reproductive health issues for women with CF.

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

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.

Selected Biochemical Parameters in Children of Mothers After Kidney Transplantation

INTRODUCTION

The number of pregnant kidney graft recipients receiving immunosuppressive drugs is increasing yearly. All potentially nephrotoxic and hepatotoxic immunosuppressive drugs penetrate through the placenta, which raises questions about their long-term effects on offspring.

OBJECTIVES

The study aimed to evaluate the influence of immunosuppressive drugs used by pregnant women after kidney transplantation on the biochemical parameters of their children.

MATERIALS AND METHODS

Forty children born to mothers after kidney transplantation (KTx) and 40 children of healthy mothers from the control group were included in the study. All graft-recipient mothers received immunosuppressive treatment during pregnancy. The study compared biochemical parameters, including urea, creatinine, potassium, and sodium, in both groups.

RESULTS

Elevated creatinine level was observed in 1 newborn in the KTx group and none of the children from the control group (P = .500). All KTx children had normal urea levels, while in the control group, 2 newborns had an increased level of urea (P = .247). Elevated potassium levels were observed in 10% of children in the KTx group and 20% of children in the control group (χ² = 0.881; P = .348). Elevated sodium levels were observed in 22.5% of children in the KTx group and 32.5% of children in the control group (χ² = 1.001; P =.317). No child in the KTx group had hyponatremia; mild hyponatremia was observed in 5% of children in the control group (P = .247).

CONCLUSION

There was no increased risk of an abnormal concentration of urea, creatinine, sodium, and potassium in the offspring of mothers after kidney transplantation using immunosuppressive drugs during pregnancy.