The effect of pregnancy on cyclosporine levels in renal allograft patients

Principles of Obstetric Pharmacology: Maternal Physiologic and Hepatic Metabolism Changes

Since the recognition of pregnancy as a special pharmacokinetic population in the late 1990s, investigations have expanded our understanding of obstetric pharmacology. Many of the basic physiologic changes that occur during pregnancy impact on drug absorption, distribution, or clearance. Activities of hepatic metabolizing enzymes are variably altered by pregnancy, resulting in concentrations sufficiently different for some drugs that efficacy or toxicity may be affected. Understanding these unique pharmacologic changes will better inform our use of medications for our pregnant patients.

Chronic Liver Disease in the Obstetric Patient

Chronic liver disease in pregnancy is rare. Historically, many chronic liver diseases were considered contraindications to pregnancy; however, with current monitoring and treatment strategies, pregnancy may be considered in many cases. Preconception and initial antepartum consultation should focus on disease activity, medication safety, risks of pregnancy, as well as the need for additional monitoring during pregnancy. In most cases, a multidisciplinary approach is necessary to ensure optimal maternal and fetal outcomes. Despite improving outcomes, pregnancy in women with the chronic liver disease remains high risk.

Moderate-to-severe psoriasis and pregnancy: impact on fertility, pregnancy outcome and treatment perspectives

Psoriasis affects 2-4% of the world's population, with no difference between men and women and 70% of patients experiencing disease onset before the age of 40, which coincides with the reproductive years. Few data are available from literature on impact of psoriasis on fertility, course and outcome of pregnancy and risk associated with treatments. Recent studies on other immune-mediated inflammatory diseases, among which psoriasis is also included, indicate that rheumatoid arthritis and inflammatory bowel diseases can impact female fertility and pregnancy outcomes especially during active disease episodes. In psoriasis hormonal and metabolic comorbidities, unhealthy lifestyles and systemic inflammation could also influence the ability to conceive, pregnancy course and birth outcomes. In this article we review current knowledge on reproductive function, course and outcome of pregnancy in women affected by moderate-to-severe psoriasis. Systemic treatments are also considered with a special focus on TNF-alpha blocking agents and implication of molecular structure on placental transportation and fetal exposure.

Successful Pregnancy Outcome in a Recipient With Simultaneous Kidney and Pancreas Transplant Who Underwent Posttransplant Metabolic Surgery

Although chronic kidney disease decreases fertility, kidney transplantation provides restoration of fertility in women, enabling them to get pregnant. Data available from registries have shown that pregnancy is feasible in solid-organ transplant recipients without significant impact on long-term graft function. Despite these reassuring data, some studies have reported that one-third of female transplant recipients are still actively being counseled against pregnancy. Here, we present a patient who received a simultaneous deceased-donor kidney and pancreas transplant and who had a favorably evolved pregnancy. The 36-yearold kidney-pancreas transplant recipient conceived 5 months after her marriage. The patient was closely followed during pregnancy by a multidisciplinary team that included a nephrologist, gynecologist, and endocrinologist. Renal function and blood glucose levels remained within normal limits. She delivered her baby normally at 31 weeks of pregnancy (1.3-kg male baby). Currently, both mother and baby are doing well. Pregnancy in combined kidney and pancreas transplant recipients with stable graft functions is feasible but remains risky. Proper planning, modification of immunosuppressive drugs, and close monitoring are the keys to optimized maternal, fetal, and graft outcomes.

Pharmacological Approach to Managing Childhood-Onset Systemic Lupus Erythematosus During Conception, Pregnancy and Breastfeeding

Pediatric patients often have poor pregnancy outcomes. Systemic lupus erythematosus predominantly impacts women in their second to fourth decade of life, with childhood-onset disease being particularly aggressive. Reproductive issues are an important clinical consideration for pediatric patients with systemic lupus erythematosus (SLE), as maintaining good disease control and planning a pregnancy are important for maternal and fetal outcomes. In this clinical review, we will consider the safety of medications in managing childhood-onset SLE during conception, pregnancy, and breastfeeding. The developing fetus is at highest risk for teratogenicity from maternal medications during the period of critical organogenesis, which occurs between the first 3-8 weeks following conception. Medications known to be teratogenic, leading to a specific pattern of malformations, include mycophenolic acid, methotrexate, and cyclophosphamide. These should be discontinued prior to a planned pregnancy or as soon as pregnancy is suspected. Hydroxychloroquine is safe and should be continued throughout pregnancy and breastfeeding in those without contraindications to it. Azathioprine and calcineurin inhibitors are felt to be compatible with pregnancy in usual doses and may be used prior to and throughout pregnancy and lactation. Non-fluorinated corticosteroids including methylprednisolone and prednisone are inactivated by the placenta and can be used if needed for maternal indication during gestation. Addition of aspirin may be considered around the 12th week of gestation for prevention of pre-eclampsia. Illustrative cases are presented that demonstrate management of adolescents with childhood-onset SLE through conception, pregnancy, and breastfeeding.

Outcome of pregnancy after renal transplantation

AIM

The aim of our study was to compare the outcome of pregnancy in patients who became pregnant within 24 months of renal transplantation and patients who became pregnant more than 24 months after renal transplantation.

MATERIALS AND METHODS

The sample population of our prospective cohort study comprised of 44 patients who became pregnant following renal transplantation. In all cases, living donors were used for renal transplantation. The patients were allocated into either group A, which included 24 patients who became pregnant more than 24 months after renal transplantation, or group B, which included 20 patients who inadvertently became pregnant within 24 months of renal transplantation. Serum creatinine and 24-hour urinary protein concentration were measured each trimester. The incidences of preeclampsia and gestational diabetes, the timing and mode of delivery, the rate of preterm labor, and the mean fetal birth weight were determined.

RESULTS

The mean gestational ages in groups A and B were 35.8±3 weeks and 34.1±2.5 weeks, respectively. The mean fetal birth weights in groups A and B were 2,480±316 g and 2,284.5±262 g, respectively. These differences were statistically significant. The incidence of preterm labor was 45.8% in group A and 55% in group B. Proteinuria was significantly higher in group B during the third trimester of pregnancy. Preeclampsia occurred in 25% of the cases in group A and 30% of the cases in group B; this difference was not statistically significant. Gestational diabetes occurred in 2 out of 24 cases in group A and 2 out of 20 cases in group B. For group A and group B, normal vaginal delivery occurred in 58.3% and 55% of cases, respectively, and cesarean section was performed in 41.6% and 45% of cases, respectively.

CONCLUSION

A longer interval between renal transplantation and pregnancy is associated with better pregnancy outcome.

Timing of Pregnancy After Kidney Transplantation and Risk of Allograft Failure

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.

Ciclosporin use during pregnancy

Ciclosporin (cyclosporine) is an immunosuppressive drug first approved for use in organ transplantation to prevent rejection. Ciclosporin is also known to be used for the treatment of psoriasis, rheumatoid arthritis, systemic lupus erythematosus and inflammatory bowel disease, among other indications. While it is recommended that all medications that are not absolutely necessary should be avoided during pregnancy, this may not be an option for many women whose quality of life is significantly impacted without treatment, or for those who must continue immunosuppressive therapy to avoid organ rejection. The purpose of this review is to provide a comprehensive report from the literature of ciclosporin exposure during pregnancy. PubMed, MEDLINE and the Cochrane Database of Systematic Reviews were searched for English-language articles published from 1970 to 2012 that included reports of pregnant women treated at any time during pregnancy with ciclosporin. On an initial search, it was evident that much of the available information is limited to pregnancy after transplant, which suggests that ciclosporin use during pregnancy appears to be associated with premature delivery and low birthweight infants. Comorbidities such as hypertension, pre-eclampsia and gestational diabetes mellitus are also reported at higher incidences than the general population. Medical literature concerning women with autoimmune disorders exposed to ciclosporin during pregnancy are currently limited to case reports and registry data, and, as such, it is difficult to determine if any risks associated with ciclosporin therapy during pregnancy are due to exposure to the drug alone or to pre-existing maternal comorbidities. The literature suggests that ciclosporin therapy during pregnancy should be carefully considered by the treating physician, but may be a safe alternative for patients with autoimmune disease refractory to conventional treatment. Continued monitoring of this patient population remains a key component to understanding the risk factors associated with ciclosporin exposure during pregnancy.

Use of cyclosporine in uterine transplantation

Uterine transplantation has been proposed as a possible solution to absolute uterine factor infertility untreatable by any other option. Since the first human attempt in 2000, various teams have tried to clarify which immunosuppressant would be most suitable for protecting the allogeneic uterine graft while posing a minimal risk to the fetus. Cyclosporine A (CsA) is an immunosuppressant widely used by transplant recipients. It is currently being tested as a potential immunosuppressant to be used during UTn. Its effect on the mother and fetus and its influence upon the graft during pregnancy have been of major concern. We review the role of CsA in UTn and its effect on pregnant transplant recipients and their offspring.

Pregnancy following liver transplantation during childhood and adolescence

More than 80% of pediatric transplant recipients will survive to reach adulthood, and many will consider having children. We report on outcomes and management of five pregnancies in four women undergoing orthotopic liver transplantation during childhood or adolescence and followed up at our Transplant Center. A retrospective clinical folder audit was performed. Mean age at transplantation was 13.3 ± 3.4 yr (range, 10-18 yr). Mean interval between transplantation and pregnancy was 15.4 ± 4.9 yr (range, 10-22 yr). Mean maternal age at conception was 28 ± 3.5 yr (range, 23-32 yr). Mean gestational age was 36.6 ± 1.7 wk. Mean birth weight was 2672 ± 249 g. Immunosuppression was cyclosporin based in three women and tacrolimus based in one woman. Pregnancy complications necessitating the induction of labor included fetal distress and rising maternal liver enzymes in two women, cholestasis of pregnancy and impaired renal graft function in one woman, fetal distress and preeclampsia in one woman. Modes of delivery were normal vaginal delivery in three women and cesarean section in one woman. No maternal or fetal deaths and no congenital malformations occurred. No episodes of rejection occurred during pregnancy. Two women experienced acute cellular rejection requiring an increase in baseline immunosuppression in the first year, following delivery. No graft losses occurred during a mean follow-up of 44 ± 17.9 months post-delivery. With careful management, pregnancy post-liver transplantation can have a successful outcome.

Long-term neurodevelopment of children exposed in utero to ciclosporin after maternal renal transplant

BACKGROUND

Immunosuppressant therapy is essential in the prevention of organ transplant rejection.

OBJECTIVE

To evaluate the long-term neurodevelopmental outcomes of children following in utero ciclosporin (cyclosporine) exposure after maternal renal transplantation.

METHODS

A cohort study with matched controls using a prospectively collected database was conducted to assess neurocognitive and behavioral outcomes using standardized measures. Thirty-nine children exposed in utero to ciclosporin therapy following maternal renal transplantation were assessed (15 single pregnancies, 24 multiple pregnancies) and compared with 38 matched unexposed children. Intelligence, visuomotor abilities, and psychologic adjustment were measured using the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R), the Beery Developmental Test of Visual-Motor Integration (VMI-4) and the Wide Range Assessment of Visual Motor Abilities (WRAVMA), and the Child Behavior Checklist (CBCL), respectively. Statistical analysis, including regression, was performed to determine the significant predictors for the main outcome, full-scale IQ (FIQ).

RESULTS

There were no significant differences in FIQ, verbal IQ (VIQ), performance IQ (PIQ) or behavioral outcomes between exposed and unexposed children or between single and multiple delivery groups. Thirty-three percent of exposed children were premature versus 0.5% in unexposed controls (p < 0.01). Prematurity was associated with low birthweight, high rates of perinatal complications, and instrumental deliveries. Relative to full-term children, premature, low birthweight children in the ciclosporin-exposed group had significantly lower FIQ and VIQ scores (101.04 vs 111.31 [p = 0.008] and 102.31 vs 113.08 [p = 0.021], respectively). Maternal IQ and socioeconomic status were positive and significant predictors for children's IQ (p < 0.001 and p = 0.03, respectively). There were no statistically significant differences in exposed children's IQ who were and were not breastfed.

CONCLUSION

In this cohort, there was no association between in utero exposure to ciclosporin and long-term neurocognitive and behavioral development in children after maternal renal transplantation. Maternal IQ and socioeconomic status are positive predictors for children's intelligence. However, maternal renal transplantation and associated co-morbidity is associated with higher rates of premature delivery and consequent poorer neurocognitive and behavioral outcomes. Proper management of maternal morbidity and improved obstetric care may improve the child's profile.

Hydronephrosis in a pregnant renal transplant patient

Although pregnancy can cause hydronephrosis in native kidneys, renal transplant dysfunction during pregnancy due to obstruction is rare. A 22-week pregnant renal transplant patient presented with deteriorating renal function (serum creatinine 5.22 mg/dL from 2.07 mg/dL 3 weeks previously). Ultrasound showed transplant hydronephrosis with the graft compressed between the gravid uterus and liver. Percutaneous nephrostomy was placed with improvement in graft function. The nephrostomy remained in situ for the rest of the pregnancy. The nephrostomy was removed postpartum with no recurrence of hydronephrosis and subsequent transplant biopsy showed no evidence of rejection. The gravid uterus may obstruct a transplanted kidney.

Pregnancy after kidney transplantation

Reproductive success is a common, expected outcome for male and female recipients of solid-organ transplants. Men can father children, and women can become pregnant and carry the fetus to delivery. There are, however, important maternal and fetal complications that need to be considered to provide optimal care to the mother and her infant. Although pregnancy is common after the transplantation of all solid organs, guidelines for optimal counseling and clinical management are limited. This review discusses information to help the physician counsel the kidney transplant recipient about risks of pregnancy for the mother and the fetus and provides information to help guide treatment of the pregnant transplant recipient.

Fertility Following Solid Organ Transplantation

Fertility is usually restored in women after solid organ transplantation, and successful pregnancies have been reported in female recipients of kidney, liver, heart, pancreas-liver, and lung transplants. However, women with solid organ allografts have higher incidence of pregnancy complications like hypertension, preeclampsia, preterm delivery. Hypertension appears to be dependent on the type of immunosuppressive agents. The influence of pregnancy on the risk of rejection is poorly known on the basis of available data. Rejection rate appears to be at least similar to the nonpregnant population. In some cases, such as in liver transplant pregnant women, even higher as compared to the nonpregnant population. Maintaining appropriate blood levels of immunosuppressive drugs is currently recommended. Malformation rate in the offsprings of transplanted women appears to not be increased; long-term follow- up of children born to allograft recipients is necessary to investigate possible developmental, immunological, or oncological disorders. We followed 70 pregnancies after kidney transplantation and nine after liver transplantation. All recipients were maintained on immunosuppressive therapy during pregnancy, except one mother who refused immunosuppression and experienced transplant rejection. Hypertension was the most frequent complication during pregnancy: in 23% of kidney transplantated mothers and in one out of nine liver transplant recipients. The only malformation observed in the newborns was the dislocation of the hip in the child of a kidney transplant recipient.

Considerations in the medical management of pregnancy in transplant recipients

Pregnancy, although rare in the patient with end-stage renal disease, is not uncommon in the transplant recipient. Physicians taking care of transplant recipients must be able to inform patients about the potential risks of pregnancy in this setting. The patient and her partner must know that the risks associated with pregnancy increase with worsening kidney function and hypertension. Current consensus opinion is that pregnancy can be relatively safely undertaken by 1 year after transplant if the patient has had no rejections during the year, allograft function is adequate, there are no infections that could affect the fetus, the patient is not taking teratogenic medications, and immunosuppressive medication dosing is stable. Consideration must be given to immunosuppression during pregnancy both with respect to the specific agents as well as the level of dosing. None of the medications are FDA category A; all are B or higher. Part of planning for pregnancy should include an evaluation of immunosuppression medication and a plan to modify the regimen prior to conception if its use may be risky for the developing fetus. Rejection can occur during a kidney transplant, so maintaining adequate immunosuppression is important. Other issues that need to be managed when caring for a pregnant transplant patient include: potential for infection (urinary tract infections are very common), hypertension, and anemia. The type of delivery, posttransplant contraception, and breast-feeding also need to be addressed.

Grossesse après transplantation rénale. Suivi obstétrical et retentissement sur le greffon rénal

OBJECTIVE

The aim of this study is to give the results of our experience about pregnancies among the renal transplantation patients and to assess the impact of the pregnancy on renal graft function.

PATIENTS AND METHODS

Twenty pregnancies from 17 renal transplant recipients were analysed and long-term outcome of the renal graft was studied. We analysed the outcomes from clinical and biological data before, during and after pregnancy.

RESULTS

Mean patient age was 30.3+/-3.5 years and meantime between transplantation and the onset of pregnancy was 62.4+/-34.5 months. There was no significant difference between the biological data before and after pregnancy. We did not observe any acute rejection. The mean maternal complications were preeclampsia in 35%, low birth weight in 39%, prematurity in 45% and cesarean sections in 55%. There is no impact of the pregnancy on the renal graft during the follow-up (3 years). The follow-up revealed 2 cases of chronic rejection.

DISCUSSION AND CONCLUSION

A multi-disciplinary approach of pregnancy in renal recipients and an interval of 2 years after kidney transplantation are necessary. There are more complications during pregnancy without increased risks of graft lose.

Renal outcome of children exposed to cyclosporine in utero

The number of pregnancies in immunosuppressed women has increased during the recent years and this has become a major part of the rehabilitation and quality of life of treated patients. Most of them are organ transplant recipients and large series from the literature have shown that children born to such women may present with intrauterine growth retardation, a condition which may be associated with significant reduction in nephron number and oligomeganephronia. On the other hand, experimental data in animals have demonstrated that in utero exposure to CsA may alter nephrogenesis and further alter renal function. Therefore offspring of organ transplant women treated with CsA exhibit a theoretical risk of renal impairment, due to both IUGR and fetal nephrotoxicity. However, despite the limited experience of long term studies in children, there is no evidence of any significant deleterious adverse effect of in utero exposure to CsA. However further studies based on large series are required in order to demonstrate that renal fetal effects have limited clinical consequences.

Planned pregnancy in a heart transplant recipient

Solid organ transplantation often leads to the return of fertility in recipients. In females of childbearing age this can be accompanied by a desire to have children. The present paper discusses a planned pregnancy in a heart transplant recipient and outlines important -management issues. These principles of management can be applied to most solid organ transplant recipients.

Pregnancy in transplant recipients

A growing number of transplant recipients are women of reproductive age or children who will reach reproductive age. Thus, menstrual function and pregnancy increasingly are important issues because fertility is restored to women who were previously unable to conceive. To date, successful pregnancies have been reported in female recipients of kidney, liver, heart, pancreas-liver, bone marrow, and lung transplants. Women often become pregnant while being maintained on numerous medications, including immunosuppressive agents, and their care providers must be able to counsel and care for them. Information to date suggests that immunosuppressive medications are safe for use during pregnancy and are important in preventing maternal and fetal complications secondary to graft rejection. Although no formal guidelines have been established due to limited clinical experience, there are a few criteria that are commonly agreed on to improve the probability of a successful pregnancy outcome and the maintenance of graft function in transplant patients. Successful management of the pregnant transplant patient requires a cooperative effort between the obstetrician and transplant team.

Renal function of children exposed to cyclosporin in utero

BACKGROUND

The use of cyclosporin (CsA) has improved graft survival in transplant (Tx) patients despite its potential nephrotoxicity. Children born to transplanted women may present with intrauterine growth retardation (IUGR). On the basis of potential reduced nephron mass both in IUGR and in newborn experimental animals exposed to CsA in utero, we investigated the renal function of children >1 year of age born to women under maintenance immunosuppression, including CsA.

METHODS

Fourteen children born to 12 Tx women (nine kidney, one pancreas-kidney, one heart, one liver) were investigated using inulin clearance (C(in)), para-aminohippuric acid clearance (C(PAH)), microalbuminuria, and electrolyte reabsorption rate.

RESULTS

Gestational age of the 14 infants was 34+/-3 weeks and birth weight 2018+/-620 g. During pregnancy, CsA trough blood level was 234+/-115 microg/l and plasma creatinine range was 96-136 micromol/l. Two children were excluded from the study because renal investigation led to a diagnosis of hereditary nephritis (one Alport syndrome, one familial dominant focal segmental glomerulosclerosis) that was retrospectively completed in the mother. Renal function tests were finally performed in 12 children at 2.6+/-1.8 years of age: BP 94+/-7/55+/-5 mmHg, C(in) 117+/-28 ml/min/1.73 m(2), C(PAH) 545+/-124 ml/min/1.73 m(2), filtration fraction 0.23+/-0.03, microalbuminuria 4.2+/-3.5 mg/mmol. Electrolyte tubular reabsorption rates and urine concentrating capacity were normal.

CONCLUSION

These results suggest that in children born to transplanted women taking CsA, renal function develops normally despite prolonged exposure in utero.