Caring for the pregnant kidney transplant recipient

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Male Renal Transplant Recipients' Experiences From Their Wives' Pregnancy and Childbirth

This study aimed to analyze male renal transplant recipients' experience with their partners' pregnancy and childbirth and to investigate their methods of nursing their condition. We performed semistructured interviews and collected data from 6 Japanese males who underwent a kidney transplant after their partner had given birth. The data were analyzed using the Qualitative Synthesis Method (KJ Method). The mean age of the participants at data collection was 40.3 ± 4.7 years, whereas it was 34.7 ± 5.8 years when the transplant was performed. The Qualitative Synthesis Method revealed 7 symbols related to the pregnancy and childbirth experience of the partners of male kidney transplant recipients. Males who received a kidney transplant struggled with severe renal disease before the transplant. They also experienced indecisiveness about whether they should go through with the transplant. However, their lives changed because of the transplant and having children. This situation resulted in a sense of responsibility and a reason to live robustly for the male kidney transplant recipients. Nevertheless, they faced distress as kidney transplant patients. Their wives supported them through this experience. They communicated to their children what they learned from the experience while effectively dealing with their condition. The improvement in their sexual function resulting from the transplant influenced their determination to get married. It is necessary to offer information about the recovery of fertility and the possibility of having a child when choosing renal replacement therapy, give explanations based on evidence, and construct a counseling system.

Pregnancy in Kidney Transplant Recipients

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.

Pregnancy After Kidney Transplantation With Maternal and Pediatric Outcomes: A Single-Center Experience

Outcomes of pregnancies after kidney transplantation were evaluated. Thirty-one pregnancies in 26 women were noted. The mean maternal age at pregnancy was 31 ± 5 years (range, 23-44 years). The interval between transplantation and conception was 54 ± 51 months (range, 7-213 months). The mean serum creatinine concentration before conception was 1.28 ± 0.4 mg/dL (range, 0.8-2.45 mg/dL), and mean estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration) was 62 ± 18 mL/min/1.73 m² (range, 27-106 mL/min/1.73 m²). There were no maternal deaths. There was 1 case of suspected acute rejection after delivery. There was 1 case of graft loss during pregnancy. Maternal complications included edema (6/26), hypertension (7/26), increase of (2/26) or appearance of proteinuria (5/26), and preeclampsia (4/26). Mean creatinine increase during pregnancy was 0.02 mg/dL. Mean creatinine 1 year after pregnancy was 1.54 mg/dL (±0.8 mg/dL). There were 19 cesarean sections. Fetal outcomes included 25 live births, 4 abortions, and 2 stillbirths. Out of 25 live births, 22 children were considered healthy, 2 children had congenital defects, and there were 2 deaths at neonatal age. Mean pregnancy age was 35 ± 4 weeks (range, 24-40 weeks). The rate of premature deliveries was 15 of 25. Mean neonate birth weight was 2363 ± 1029 grams (range, 490-4100 grams). The rate of babies small for gestational age was 19%. During follow-up (range, 0.5-30 years) 5 of 26 patients lost grafts (between 3 and 15 years after pregnancy); most (20) of the children previously considered healthy had good long-term development. Our results confirm that risk of pregnancy in kidney transplant recipients can be accepted, and children considered healthy at delivery develop well.

Pregnancy in Liver Transplantation

Pregnancy after liver transplantation (LT) is increasingly common and is a frequent scenario that transplant physicians, obstetricians, and midwives encounter. This review summarizes the key issues surrounding preconception, pregnancy-related outcomes, immunosuppression, and breastfeeding in female LT recipients. Prepregnancy counseling in these patients should include recommendations to delay conception for at least 1-2 years after LT and discussions about effective methods of contraception. Female LT recipients are generally recommended to continue immunosuppression during pregnancy to prevent allograft rejection; however, individual regimens may need to be altered. Although pregnancy outcomes are overall favorable, there is an increased risk of maternal and fetal complications. Pregnancy in this cohort remains high risk and should be managed vigilantly in a multidisciplinary setting. We aim to review the available evidence from national registries, population-based studies, and case series and to provide recommendations for attending clinicians.

Childbirth and Care Difficulties of Female Kidney Transplantation Recipients

BACKGROUND

For mothers who experience transplants, pregnancy and childcare can have significant consequences on their quality of life. This study aims to investigate the childcare-related suffering faced by women who gave birth following kidney transplantation.

METHODS

Data were collected from 65 Japanese kidney transplant recipients from 21 hospitals who had given birth after transplant. The questionnaire included questions concerning the childcare-related suffering of the female kidney transplant recipients. The data were analyzed using KH Coder for the qualitative text mining analysis.

RESULTS

The results of the co-occurrence network of words and hierarchical cluster analysis revealed 6 categories that were identified regarding the difficulties in childcare experienced by mothers who gave birth after kidney transplantation: comparing themselves with healthy mothers, parenting priorities, getting tired, not being able to take medicine on time, carefully giving the child a hug, being unable to give breast milk, having regular doctor checkups, and having to leave the child.

CONCLUSION

Recipients experience suffering related to the lifestyle changes that occur as a matter of course during childcare. Recipients are exhausted because of how busy they are with childcare, and they sometimes forget to take their medicine. It is necessary to confirm the living situations of recipients after birth and provide support for their self-management based on their new lifestyles.

[Sexuality, fertility and pregnancy after kidney transplantation]

AIMS

To describe sexuality and fertility alterations secondary to chronic kidney disease and their outcomes after renal transplantation.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: erectile dysfunction; impotence; sexuality; pregnancy; fertility; renal transplantation. Publications obtained were selected based on methodology, language, date of publication (last 10 years) and relevance. Prospective and retrospective studies, in English or French, review articles; meta-analysis and guidelines were selected and analyzed. This search found 706 articles. After reading titles and abstracts, 76 were included in the text, based on their relevance.

RESULTS

The observed prevalence of erectile dysfunction is high in men with chronic kidney disease. The causes of erectile dysfunction are numbers and its origin is often multifactorial. Most of the time, kidney transplantation improves sexuality and the management of erectile dysfunction in transplanted men is similar to the general population. Improvement in sexuality in men and women after kidney transplantation may conduct to pregnancy. The outcomes of pregnancy after transplantation are quite good in absence of risk factors such as time to pregnancy less than 1 year after transplantation, uncontrolled high blood pressure, and decreased renal function of the graft. Adaptation of immunosuppression may be required to avoid any teratogenicity for the fetus.

CONCLUSION

Kidney transplantation improves sexuality and fertility in men and women with chronic kidney disease.

AISF position paper on liver transplantation and pregnancy: Women in Hepatology Group, Italian Association for the Study of the Liver (AISF)

After the first successful pregnancy in a liver transplant recipient in 1978, much evidence has accumulated on the course, outcomes and management strategies of pregnancy following liver transplantation. Generally, liver transplantation restores sexual function and fertility as early as a few months after transplant. Considering that one third of all liver transplant recipients are women, that approximately one-third of them are of reproductive age (18-49 years), and that 15% of female liver transplant recipients are paediatric patients who have a >70% probability of reaching reproductive age, the issue of pregnancy after liver transplantation is rather relevant, and obstetricians, paediatricians, and transplant hepatologists ever more frequently encounter such patients. Pregnancy outcomes for both the mother and infant in liver transplant recipients are generally good, but there is an increased incidence of preterm delivery, hypertension/preeclampsia, foetal growth restriction, and gestational diabetes, which, by definition, render pregnancy in liver transplant recipients a high-risk one. In contrast, the risk of congenital anomalies and the live birth rate are comparable to those of the general population. Currently there are still no robust guidelines on the management of pregnancies after liver transplantation. The aim of this position paper is to review the available evidence on pregnancy in liver transplant recipients and to provide national Italian recommendations for clinicians caring for these patients.

Contraception After Kidney Transplantation, From Myth to Reality: A Comprehensive Review of the Current Evidence

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.

Contraception in women after organ transplantation

INTRODUCTION

Organ transplantation has improved the quality and length of life for many people suffering from end-stage diseases, among them women of reproductive age. Therefore, it has made pregnancy possible for those previously unable to conceive. Nevertheless, conception itself should be desired and properly timed in these specific patients to ensure the best possible perinatal outcome.

OBJECTIVE

The objective of the study was to assess whether female graft recipients apply proper family planning methods and use effective contraception.

METHODS

In a single-center, observational study, information was collected using a self-administered questionnaire distributed among 100 female graft recipients (post-transplant group [TG]) and 67 healthy female volunteers (control group [CG]). The survey covered data regarding present menstrual patterns, sexual activity, gynecological counseling, and contraceptive methods used.

RESULTS

Female graft recipients were more sexually active after than before transplantation (87% vs 64%, P = .0001) and equally active as controls. Sexually active post-transplantation patients used contraception less frequently than sexually active controls (51.72% vs 82.76%, P < .0001). Condoms were the most frequently used method in TG, and oral contraception in CG. Oral contraception was used more rarely by counseled graft recipients than by counseled controls (3.9% vs 60.7%, P < .0001). After counseling, intrauterine device usage increased and oral contraception usage decreased in TG. Among women with chronic diseases, intrauterine device was used more often in TG (4% vs 0%), whereas oral contraception was used more often in CG (8.3% vs 50%, P < .0001).

CONCLUSIONS

Despite the fact that post-transplantation women of reproductive age have many indications for highly effective contraception, only few of them actually use it. Contraceptive counseling has to be included as part of routine post-transplantation care by all health professionals involved in the management of female graft recipients of reproductive age.

Immunophenotypic profile and increased risk of hospital admission for infection in infants born to female kidney transplant recipients

Children born to female kidney recipients are exposed to immunosuppressive drugs during gestation. Little is known about their immune system at birth or in the long term. Twenty-eight children born to female kidney recipients and 40 full-term children born to healthy mothers were evaluated. T, B, NK, NKT, γδT cells were assessed by flow cytometry and functional evaluation of T and dendritic cells after in vitro activation was performed at birth and at 8 months of age. At birth, infants born to female kidney recipients showed lower numbers of CD4+ T, NKT and intense reduction of B cells (median cells/mm(3) , transplant: 153.7 X control: 512.4; p < 0.001). There was also a reduced percentage of activated CD8+ T and of CD4+ regulatory T cells. Activated memory and exhausted memory B cells showed higher percentages among children exposed to immunosuppressors when compared to control group. At 8 months, most immune alterations were no longer observed, but four children still had low numbers of some lymphocyte subsets at this age. Children born to female kidney recipients had 4.351 (95% CI: 1.026-15.225; p = 0.046) higher risk of hospital admission in the first months of life-some, with severe clinical manifestations-than those born to healthy women.

Chronic kidney disease in pregnancy

Parturients with renal insufficiency or failure present a significant challenge for the anesthesiologist. Impaired renal function compromises fertility and increases both maternal and fetal morbidity and mortality. Close communication amongst medical specialists, including nephrologists, obstetricians, neonatologists and anesthesiologists is required to ensure the safety of mother and child. Pre-existing diseases should be optimized and close surveillance of maternal and fetal condition is required. Kidney function may deteriorate during pregnancy, necessitating early intervention. The goal is to maintain hemodynamic and physiologic stability while the demands of the pregnancy change. Drugs that may adversely affect the fetus, are nephrotoxic or are dependent on renal elimination should be avoided.

Pregnancy management of diabetic renal transplant patients

Advances in medical care and options for medications for diabetic kidney transplant recipients have allowed for successful pregnancies to be carried to full term. End-stage renal disease leads to impaired fertility. Fertility is restored 1 to 6 months after a successful kidney transplant. Poor glycemic control near the conception period leads to a higher incidence of major fetal malformations and spontaneous abortion. Preconception counseling about risks of medications, control of comorbid conditions, stability of allograft function, and potential risks to mother, fetus, and allograft has to be done. Close and careful monitoring of mother, fetus, and allograft is important in ensuring a good outcome.

Pregnancy in renal transplantation: Recipient and donor aspects in the Arab world

OBJECTIVE

There are many kidney transplant recipients and living donors of reproductive age, and the prevalence of pregnancies in kidney transplant recipients can reach 55% in the Middle Eastern countries. Living kidney donation is predominant in this region. As the risks and outcomes of pregnancy should be a part of counselling for both recipients and donors, we reviewed available reports on maternal and foetal outcomes in these particular populations.

METHODS

Information was obtained from retrospective analyses of a large database, and from single-centre reports indexed in PubMed on pregnancy in donors and kidney transplant recipients. The keywords used for the search included 'fertility', 'kidney disease', 'pregnancy', 'maternal/foetal outcomes', 'kidney transplant recipient', 'immunosuppression side-effects', 'living donor' and 'Arab countries'.

RESULTS

Pregnancies in kidney transplant recipients are most successful in those with adequate kidney function and controlled comorbidities. Similarly to other regions, pregnant recipients in the Middle East had a higher risk of pre-eclampsia (26%) and gestational diabetes (7%) than in the general population. Caesarean section was quite common, with an incidence rate of 61%, and the incidence of pre-term birth reached 46%.

CONCLUSIONS

Most living donors can have successful pregnancies and should not be routinely discouraged. Women who had pregnancies before and after donation were more likely to have adverse maternal outcomes (gestational diabetes, hypertension, proteinuria, and pre-eclampsia) in the latter, but no adverse foetal outcomes were found after donation. The evaluation before donation should include a gestational history and counselling about the potential risks.