Pregnancy outcomes in female renal recipients: a comparison of systemic lupus erythematosus with other diagnoses

Systemic Lupus Erythematosus and Pregnancy: a Portuguese Case-Control Study

Pregnancy in systemic lupus erythematosus (SLE) patients is associated with an increased risk of adverse outcomes. During pregnancy, SLE patients have a higher rate of miscarriage, stillbirth, preterm delivery, fetal growth restriction, or hypertensive disorders of pregnancy. To date, only a few case-control studies were published with the purpose to evaluate the magnitude of risk associated with pregnancy in lupus patients. The aim of our study was to evaluate the maternal and fetal outcomes in a cohort of Portuguese SLE patients and to compare it with a group of healthy pregnant women. We conducted a retrospective case-control study that included all pregnant women with SLE managed at a Portuguese tertiary center, between 2010 and 2019. Pregnancy outcomes were compared between SLE patients and a group of matched healthy pregnant women. Baseline maternal data was collected, and maternal-fetal and neonatal outcomes were evaluated. One hundred twenty-four SLE pregnancies were included. Of the patients, 95.2% were in remission at conception. In 13.7% of cases, a lupus flare was diagnosed during gestation and in 17.9% in the postpartum period. The live birth rate was 84.6%, and the incidence of adverse outcomes was 40.3% (OR 2.64, 95% CI 1.67-4.18). Considering only patients in remission at conception, the presence of adverse outcomes remained significantly higher (36.8% vs. 20.3%, P < 0.01). Miscarriage rate was 15.3% (OR 5.85, 95% CI 2.57-13.34) and preterm delivery occurred in 12.4% of the patients (OR 1.72, 95% CI 0.83-3.57). Preeclampsia prevalence was higher in SLE patients (OR 3.92, 95% CI 1.32-11.57). In the SLE group, the newborn admission to an intensive care unit rate was increased (OR 4.99, 95% CI 1.47-16.90). No neonatal or maternal deaths were reported. In our study, pregnancy with SLE was associated with an increased incidence of adverse outcomes, even in a population of SLE patients with well-controlled disease.

Risk of adverse pregnancy outcomes in Japanese systemic lupus erythematosus patients with prior severe organ manifestations: A single-center retrospective analysis

BACKGROUND

Systemic lupus erythematosus (SLE) increases the incidence of adverse pregnancy outcomes (APOs). Nevertheless, most of the data on SLE pregnancies were derived from database studies in which details of the pregnancies were unavailable, and no consensus exists on the risk of APO in patients with prior severe organ manifestations.

METHODS

SLE patients followed by rheumatologists and gynecologists throughout pregnancy at our institute were retrospectively identified, and their data between April 2003 and December 2020 were reviewed from electronic records. We assigned patients based on the presence of prior severe organ manifestation (renal/neurological manifestation, prior treatment with methylprednisolone pulse therapy/prednisolone 1 mg/kg/day/biological or cytotoxic therapy) and compared the incidence of overall and serious APO (maternal death, pregnancy loss, preterm birth <32 weeks, birthweight <1500 g, Apgar score <7 at 5 min and birth defect).

RESULTS

This study included 34 pregnancies in 32 patients; 23 pregnancies in 22 patients were classified as SLE with prior severe organ manifestation. There was no statistical difference in the incidence of overall APO between the two groups (52.2% vs 45.5%, P = 1). Among patients with prior severe organ manifestation, 17.4% had serious APO. A detailed electronic health record search revealed specific causes of APO in all pregnancies with serious APO, except the presence of prior severe organ manifestation.

CONCLUSION

The incidence of overall APO in SLE patients was not affected by prior severe organ manifestation. Although the incidence of serious APOs increased in patients with previous severe organ manifestation, there were other risk factors for poor pregnancy outcomes besides prior lupus severity. Therefore, proper management by rheumatologists and gynecologists may enable patients with prior severe organ manifestation to safely deliver healthy babies.

In utero exposure to Azathioprine in autoimmune disease. Where do we stand?

Azathioprine (AZA), an oral immunosuppressant, is safe during pregnancy. Some reports suggested different impairments in the offspring of mothers with autoimmune diseases (AI) exposed in utero to AZA. These observations are available from retrospective studies or case reports. However, data with respect to the long-term safety in the antenatally exposed child are still lacking. The aim of this study is to summarize the current knowledge in this field and to focus on the need for a prospective study on this population. We performed a PubMed search using several search terms. The actual data show that although the risk of congenital anomalies in offspring, as well as the infertility risk, are similar to those found in general population, there is a higher incidence of prematurity, of lower weight at birth and an intra-uterine delay of development. There is also an increased risk of materno- fetal infections, especially cytomegalovirus infection. Some authors raise the interrogations about neurocognitive impairment. Even though the adverse outcomes might well be a consequence of maternal illness and disease activity, interest has been raised about a contribution of this drug. However, the interferences between the external agent (in utero exposure to AZA), with the host (child genetic susceptibility, immune system anomalies, emotional status), environment (public health, social context, availability of health care), economic, social, and behavioral conditions, cultural patterns, are complex and represent confounding factors. In conclusion, it is necessary to perform studies on the medium and long-term outcome of children born by mothers with autoimmune diseases, treated with AZA, in order to show the safety of AZA exposure. Only large-scale population studies with long-term follow-up will allow to formally conclude in this field. TAKE HOME MESSAGES.

Lupus Nephritis and Kidney Transplantation: Where Are We Today?

Lupus nephritis (LN) is the cause of end-stage kidney disease (ESKD) for 1.9% of the ESKD population in the United States. Although the incidence rates of ESKD from LN stopped rising in recent years, racial disparities in waiting time, pre-emptive kidney transplant, and transplant outcomes still exist. Patients with LN who progress to ESKD tend to be female, of African ancestry, and young. Kidney transplantation is safe in this population and associated with a substantial survival benefit, primarily due to reduced deaths from cardiovascular disease and infection. Transplant outcomes for patients with ESKD due to LN are similar to those without LN.

Pregnancy outcomes among Chinese women with and without systemic lupus erythematosus: a retrospective cohort study

OBJECTIVE

To completely and quantifiably determine the effect of systemic lupus erythematosus (SLE) on pregnancy outcomes in a Chinese cohort.

DESIGN

A retrospective cohort study.

SETTING

Data were collected at a tertiary medical centre located in Shanghai, China, from September 2011 to May 2017.

PARTICIPANTS

We assigned 338 pregnant women with SLE to the study cohort and 1014 randomly selected pregnant women without SLE (three for every woman with SLE) to a comparison cohort. The relevant medical records of all pregnant women were retrospectively reviewed. Cases of multiple pregnancy and cases in which an artificial abortion was performed for personal reasons were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

Maternal and fetal outcomes were primary outcomes, and management of antenatal care was the secondary outcome.

RESULTS

The risks of pregnancy-induced hypertension (OR 2.68, 95% CI 1.75 to 4.09), pre-eclampsia (OR 3.13, 95% CI 1.95 to 5.03) and premature rupture of membranes (OR 2.53, 95% CI 1.46 to 4.40) were significantly different between women with and without SLE. Gestational diabetes was negatively associated with SLE in pregnant women (OR 0.49, 95% CI 0.28 to 0.85). Pregnant women with SLE displayed significantly higher rates of fetal loss (OR 10.23, 95% CI 5.08 to 20.59), including spontaneous abortion (OR 4.42, 95% CI 1.52 to 12.80), therapeutic abortion (OR 16.57, 95% CI 5.80 to 47.35) and stillbirth (OR 13.25, 95% CI 1.49 to 118.11), and a higher risk of preterm birth (OR 3.15, 95% CI 2.21 to 4.50), intrauterine growth restriction (OR 2.20, 95% CI 1.35 to 3.58), a child who was small for the gestational age (OR 1.86, 95% CI 1.11 to 3.13), a caesarean section (OR 4.73, 95% CI 3.30 to 6.80) or a neonatal intensive care unit admission (OR 3.48, 95% CI 2.21 to 5.48) than women in the non-SLE population after adjusting for confounding factors.

CONCLUSIONS

In this study, SLE significantly increased the risk of adverse pregnancy outcomes. Therefore, a preconception assessment and close antenatal monitoring by both rheumatologists and obstetricians should be performed in pregnant women with SLE.

Autoantibodies in lupus nephritis patients requiring renal transplantation

The goal of this nested case-control study was to compare autoantibody profiles in systemic lupus erythematosus (SLE) patients with lupus nephritis (LN), lupus nephritis patients requiring renal transplantation (LNTP) and a SLE control group without nephritis (CON). Sera were assayed for a variety of autoantibodies by addressable laser bead immunoassay (ALBIA) and enzyme-linked immunoassay (ELISA) and to dsDNA by Crithidia luciliae assay. The frequency of nucleosome autoantibodies was significantly greater in the LNTP group (79%) compared to the LN (18%) and CON (9%) groups ( P < 0.0005). The frequency of other autoantibodies, including anti-dsDNA, did not differ significantly between groups. Among patients with LN, the odds of progressing to renal transplantation was 16-fold higher (OR 16.5 [95% CI 2.5, 125.7], P = 0.0005) in patients testing positive for anti-nucleosome antibodies compared to those who tested negative. Furthermore, the level of anti-nucleosome antibodies was significantly ( P < 0.00005) higher in the LNTP group (3.69 ± 2.79) than the LN (0.51 ± 0.51) and CON (0.34 ± 0.44) groups. Review of 48 renal biopsies from 29 patients indicated that there was no difference in renal histological classification among patients with anti-nucleosome antibodies compared to those who tested negative. Our observations suggest that nucleosome autoantibodies are a biomarker for more severe SLE renal disease requiring transplantation. Lupus (2007) 16, 394—400.

Pregnancies in women receiving renal transplant for lupus nephritis: description of nine pregnancies and review of the literature

Background

Few data are available on pregnancy in renal transplanted women for lupus nephritis (LN).

Methods

Among 38 women with LN who received a renal transplant in our Unit, three had nine pregnancies. During the pregnancies, patients were followed by a multidisciplinary team including gynecologists and nephrologists.

Results

Two patients received a living related and one a deceased kidney transplant. The immunosuppressive therapy consisted of steroids calcinurin inhibithors and mycophenolate mofetil. The last drug was substituted with azathioprine in prevision of pregnancy. All patients had normal renal function and urinalysis. In two patients some signs of immunological activity persisted after transplantation. Five pregnancies ended in miscarriage and four in live births. Two pregnancies were uneventful. Pre-eclampsia occurred in a hypertensive patient in two pregnancies that ended in preterm delivery in one case and in a small for gestation age in both cases. And finally, follow-up graft function and urinalysis continued to be normal in all patients.

Conclusions

After renal transplantation our LN women continue to have frequent miscarriages. The other pregnancies ended in live births and, with the exception of pre-eclampsia in a hypertensive patient, no renal or extra-renal complications occurred during or after pregnancy, even in cases with active immunological tests.

The challenge of pregnancy for patients with SLE

Pregnancy poses an important challenge for doctors looking after women with systemic lupus erythematosus. Knowledge about safety of medications, the effect of pregnancy on such disease, and vice versa, together with multidisciplinary team care, are basic cornerstones needed to provide the best obstetric and medical care to these women. Pre-conceptional counselling constitutes the ideal scenario where a patient's previous obstetric history, organ damage, disease activity, serological profile and additional medical history can be summarized. Important issues regarding medication adjustment, planned scans and visits, and main risks discussion should also be raised at this stage. Planned pregnancies lead to better outcomes for both mothers and babies. Close surveillance throughout pregnancy and the puerperium, and tailored management approach guarantee the highest rates of successful pregnancies in these women.

Pregnancy and renal outcomes in lupus nephritis: an update and guide to management

Systemic lupus erythematosis (SLE) commonly affects women of child bearing-age, and advances in treatment have resulted in an increasing number of women with renal involvement becoming pregnant. Knowledge of the relationship of the condition with respect to fertility and pregnancy is important for all clinicians involved in the care of women with lupus nephritis because they have complicated pregnancies. Presentation of lupus nephritis can range from mild asymptomatic proteinuria to rapidly progressive renal failure and may occur before, during, or after pregnancy. The timing of diagnosis may influence pregnancy outcome. Pregnancy may also affect the course of lupus nephritis. All pregnancies in women with lupus nephritis should be planned, preferably after more than six-months of quiescent disease. Predictors of poor obstetric outcome include active disease at conception or early pregnancy, baseline poor renal function with Creatinine >100 μmol/L, proteinuria >0.5 g/24 hours, presence of concurrent antiphospholipid syndrome and hypertension. In this review the most recent studies of pregnancies in women with lupus nephritis are discussed and a practical approach to managing women prepregnancy, during pregnancy and post-partum is described.

Pregnancy after transplantation

The National Transplantation Pregnancy Registry (NTPR) was established in 1991 to study the outcomes of pregnancies in female transplant recipients and pregnancies fathered by male transplant recipients. Data from the NTPR have helped to endorse the reassurances from publications of smaller experiences that successful pregnancies are possible in the transplant population. In our last review for this journal (2000), we noted that important future issues would include the reassessment of prepregnancy guidelines, gestational and organ-specific problems, the role of new immunosuppressive drugs, and the long-term effects of pregnancy on both graft and child. Data collected by the NTPR over the last 7 years have addressed these issues, thus providing additional information for health care providers of transplant recipients of childbearing age. There has been some refinement of prepregnancy guidelines, but there is a need for additional data collection so that organ-specific outcomes and risks can further be identified. To date, the outcomes of the children followed have been encouraging, and specific remote effects have not been identified, but continued surveillance is still vital. Of special concern are the new immunosuppressive drugs, specifically for mycophenolate mofetil (CellCept, Roche Laboratories Inc., Nutley, New Jersey), where data reported to the NTPR and through postmarketing surveillance have shown an increased incidence of nonviable outcomes and a specific pattern and increased incidence of malformation in the newborn, which has resulted in a pregnancy category change. Newer information points to an increased need for vigilance among centers and continued monitoring of pregnancy outcomes in this population. As the first reported pregnancy after transplantation occurred in a kidney recipient 50 years ago, in March 1958, this review also highlights the first reported pregnancies in other solid organ recipients.

Systemic lupus erythematosus and pregnancy

PURPOSE OF REVIEW

Pregnancy in patients with systemic lupus erythematosus is associated with a high risk of maternal disease exacerbation and adverse fetal outcome. This review summarizes recent published findings on lupus pregnancy.

RECENT FINDINGS

The literature is in agreement that for most women with inactive and stable systemic lupus erythematosus, pregnancy is safe for both mother and fetus. The main risk factors for adverse pregnancy course and outcome are active disease, nephritis with proteinuria, hypertension, and maternal serum antibodies to SS-A/Ro, SS-B/La, cardiolipin, beta2-glycoprotein I, and lupus anticoagulant. Recent studies have broadened our understanding of the immunological mechanism underlying congenital heart block induced by anti-Ro/La antibodies. In addition, the approach to oral contraceptives has been modified on the basis of two well controlled studies suggesting that they do not cause exacerbation of inactive or mild disease.

SUMMARY

Pregnancy in patients with systemic lupus erythematosus is safe and manageable provided the disease is stable. Patients should be evaluated before pregnancy for pregestational risk factors and be closely followed during pregnancy. In most cases of lupus flare during pregnancy, the disease can be safely managed.

Lupus and pregnancy: complex yet manageable

Systemic lupus erythematosus is a chronic multi-system autoimmune disease that occurs predominantly in women of childbearing age. The risk of complications and adverse fetal outcomes in pregnant women with lupus is high. Moreover, pregnancy can cause flares of lupus disease activity necessitating maternal immunosuppressive intervention. Interestingly, many potential complications of pregnancy present as symptoms of lupus making diagnosis and treatment a challenge. Advancing technology and better understanding of the maternal-fetal dyad in lupus have improved outcomes in lupus pregnancies over the last 40 years. This article will briefly review the important issues in pregnancies complicated by lupus and provide a general guideline to physicians for monitoring and treatment.

Pregnancy after lupus nephritis

Systemic lupus erythematosus (SLE) is an autoimmune disease that affects primarily women, commonly in their reproductive years but does not influence fertility. For these reasons, the clinician has often to face the many problems of pregnancy in patients with SLE including the influence of SLE on fetal outcome and that of pregnancy on SLE. As there is increasing evidence of an important role of sex hormones in immunity, the influence of pregnancy on SLE is probably due to the changes in sex hormone levels during pregnancy that are more important than in any other period of life. Early reports emphasized a high fetal and maternal risk in particular in patients with lupus nephritis. However in the same period the prognosis of lupus nephritis was poor, so it was difficult to know whether pregnancy actually influenced the prognosis of the disease. More recent prospective studies indicate that pregnancy is safe for the majority of mothers if it is planned when SLE is quiescent. Instead, although fetal risk has been progressively reduced in the last 40 years, it continues to be higher than that occurring in pregnancies of healthy women. In particular the presence of antiphospholipid antibodies considerably worsen the fetal outcome.

New insights into pregnancy-related complications in systemic lupus erythematosus

Pregnancy in patients with systemic lupus erythematosus (SLE) presents an additional risk to an already complex clinical situation--overlap in symptoms between changes of pregnancy and SLE, presence of antiphospholipid antibodies, and need for potentially teratogenic medications can all complicate the management of pregnant patients with SLE. Studies demonstrate that, with careful planning, the majority of patients with lupus can complete pregnancy without serious complications. Recent developments are modified instruments to measure disease activity in pregnancy, increasingly common continuation of hydroxychloroquine during pregnancy, more frequent use of in vitro fertilization, and more aggressive fetal monitoring in patients positive for anti-Sjögren's syndrome (SS)-A/Ro or anti- SS-B/La antibody.