Safety considerations: breastfeeding after transplant

Organ transplant is an effective treatment for end-stage organ failure. For women, restoration of organ function can restore fertility and the ability to successfully carry a pregnancy. Posttransplant pregnancies have been reported among recipients of all types of solid organ transplants via case and center reports plus registry data. Stable graft function is dependent on prevention of rejection, currently accomplished by using maintenance immunosuppressant medications, to which the fetus is exposed in utero. Common among neonatal outcomes in transplant recipients are preterm and low-birth-weight infants. Emotional, nutritional, and immunologic benefits of breastfeeding have been well-documented and could be valuable for these newborns. Concern must be directed at the effects of the child's exposure to immunosuppressive agents excreted into the breast milk. Breastfeeding could be considered in transplant recipients if it can be shown that the level of exposure does not result in risks to the newborn, immediately and throughout childhood. Despite concerns of health care professionals, some recipients have chosen to breastfeed. Breastfeeding after transplant must be approached with consideration of many issues, and the potential risks require further study. This review focuses on benefits of breastfeeding, common immunosuppressive agents used in organ transplant recipients, a summary of the reports of women who have breastfed their infants while on immunosuppressive therapy and the published studies on breastfeeding and immunosuppressive agents. Recommendations are provided to guide health care professionals to help mothers receiving immunosuppressive agents to make informed choices about breastfeeding their infants.

The anion gap and routine serum protein measurements in monoclonal gammopathies

BACKGROUND AND OBJECTIVES

An abnormal anion gap and an increased total protein and globulin are clues to the diagnosis of monoclonal gammopathy. We explored the utility of these markers in IgG, IgA, IgM, and free light chain monoclonal gammopathies.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The anion gap, Na(+) - (Cl(-) + HCO(3)(-)), corrected for hypoalbuminemia, was calculated in patients with monoclonal gammopathies. Exclusion criteria were serum calcium >10.5 mg/dl and/or creatinine >2 mg/dl.

RESULTS

Among 287 patients, 242 remained after applying exclusion criteria (109 IgG, 64 IgA, 21 IgM, and 48 light chain); 36% of 242 patients required correction for hypoalbuminemia. The anion gap was decreased (<10) in 22% of IgG and increased (>15) in 31% of IgA monoclonal gammopathies. IgM did not affect the gap. In light chain gammopathies, the anion gap showed no consistent trend (15% increased, 17% decreased). Mean clonal IgG, IgA, and IgM concentrations were 10-fold higher than mean clonal free light chain concentrations in the respective monoclonal gammopathies (P < 0.001). These paraprotein level disparities were reflected in significantly increased mean serum total protein and globulin concentrations in IgG, IgA, and IgM versus free light chain monoclonal gammopathies, where mean total protein and globulin levels were within normal limits (P < 0.001).

CONCLUSIONS

The anion gap was significantly altered in IgG and IgA monoclonal gammopathies, but it was not a sensitive tool for suspecting the diagnosis. In light chain monoclonal gammopathies, the anion gap, total protein, and globulin did not provide reliable diagnostic clues.

Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation

From the first reports of pregnancy in each of the organ groups to the present, concerns varied and were specific to the type of transplant. Organ-specific issues still require additional attention and analyses. Lung recipients appear at greatest risk for poorer pregnancy outcomes. Given these ongoing concerns and the constant advent of new developments, clinicians are responsible for providing pregnancy counseling in all pre- and posttransplant recipients of childbearing age. As individual physicians and centers accrue experience with these major therapeutic decisions, it is critical that both positive and negative outcomes be reported in appropriate settings-symposia, meetings, publications, and registries. Future analyses from the NTPR are directed at potential effects of newer immunosuppressive regimens, not only from immediate exposure, but also from continued exposures such as may occur from breastfeeding. As the registry study design allows for contact between registry staff and recipients and their health care providers, efforts are ongoing to analyze long-term outcomes of parent and child. Continued close collaboration among specialists will help to identify potential pregnancy risks in these populations, particularly as new immunosuppressive agents are developed. Therefore, centers are encouraged to report all pregnancy exposures in transplant recipients to the NTPR. The 50th anniversary of the first posttransplant pregnancy (reported by Joseph Murray, et al. (11)) was in March 2008. With this important landmark event and with ongoing pregnancy issues concerning posttransplant pregnancy safety, this is an ideal time to raise the awareness of the need for continued worldwide cooperation for data collection. Enhanced assessment of pregnancy safety is essential to the development of guidelines for counseling and management of pregnancy in the transplant population.

Report from the National Transplantation Pregnancy Registry: outcomes of pregnancy after transplantation

Experience in the field of pregnancy posttransplantation has been gained through continued case reports, center reports, and registry data. The NTPR maintains an ongoing active database to study the safety of pregnancy and includes the outcomes of female transplant recipients as well as male recipients who father pregnancies. Analyses are ongoing and include long-term followup of recipients' graft status and of their offspring. For the most part, guidelines proposed in 1976 for counseling recipients remain applicable (30). While these counseling guidelines were formulated for kidney recipients, they may be extrapolated to other organ recipients as well. Organ-specific issues should also be considered in managing and counseling female transplant recipients. Recipients should be in general good health, and graft function should be stable and, ideally, rejection-free. There should be optimal control of comorbid conditions such as hypertension and diabetes prior to conception. While the shortest safe interval from transplant to conception has not been established, 1 year is a reasonable milestone, given the prerequisites of stable, adequate graft function and maintenance-level immunosuppression. During pregnancy, maintenance-medication regimens should be continued with vigilant monitoring for effective drug levels and drug side effects with appropriate dose adjustment. These pregnancies are high-risk and require close maternal and fetal surveillance through coordinated care among maternal-fetal medicine specialists and transplant personnel. Of the live born reported to the NTPR, a higher incidence of structural malformations has been seen with MMF exposures during pregnancy when compared with the overall kidney transplant recipient offspring group. Three of the four defects included microtia (ear deformity), suggesting a pattern of malformations. However, live-born outcomes without structural malformations have also been noted in the MMF cohort. No structural defects have yet been reported with early pregnancy sirolimus exposures in a limited number of recipients evaluated. Limitations in assessing congenital malformation risk and MMF exposure include methodology and potential reporting bias, small sample size, and our inability to exclude other comorbid factors such as non-immunosuppressive drug effects or other susceptibilities in this population. It is incumbent upon transplant professionals to be aware of any additional risk to the fetus from immunosuppressive medications relative to the potential improvement in maternal graft function/survival conferred by each of these agents. Given the ongoing concerns with the newer immunosuppressive agents, clinicians are responsible for providing pregnancy counseling in all pre- and post-transplant recipients of childbearing age. Centers are encouraged to report all pregnancy exposures in transplant recipients to the NTPR. Future analyses from the NTPR are directed at potential effects of these newer immunosuppressive regimens, not only from immediate exposure but also from continued exposure that may occur from breastfeeding. As the registry study design allows for contact between registry staff and recipients and their health care providers, efforts are ongoing to analyze the long-term outcomes of parents and children. Continued close collaboration among specialists will help to better identify potential pregnancy risks in these populations, particularly as new immunosuppressive agents are developed. The fiftieth anniversary of the first post-transplant pregnancy (reported by Joseph Murray et al.) (31) will be in March 2008. With this important date approaching and with ongoing pregnancy issues concerning post-transplant pregnancy safety, this is an ideal time to raise awareness of the need for continued worldwide cooperation for data collection. Enhanced assessment of pregnancy safety is essential to the development of guidelines for counseling and management of pregnancy in the transplant population.

Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation

Experience in the field of pregnancy after transplantation has been gained through continued case reports, center reports, and registry data. The NTPR maintains an ongoing active database to study the safety of pregnancy and includes the outcomes of female transplant recipients as well as male recipients who father pregnancies. Analyses are ongoing and include long-term follow-up of recipients' graft status and of their offspring. For the most part, guidelines proposed in 1976 for counseling recipients remain applicable. While these counseling guidelines were formulated for kidney recipients, they may be extrapolated for other organ recipients as well. Organ-specific issues should also be considered in managing and counseling female transplant recipients. Recipients should be in general good health and graft function should be stable and ideally rejection free. They should have optimal control of comorbid conditions such as hypertension and diabetes prior to conception. While the shortest safe interval from transplant to conception has not been established, one year is a reasonable milestone, given the prerequisites of stable, adequate graft function and maintenance level immunosupression. During pregnancy, stable medication regimens should be changed as little as possible, and close maternal and fetal surveillance are required. These pregnancies are high-risk and require coordinated care among maternal fetal medicine specialists and transplant personnel. The pregnancy issues that face recipients and caretakers with the current adjunctive therapies and differing combinations of immunosuppressive regimens continue to require further study. The most pressing issue is the question of whether fetal exposure to mycophenolate mofetil or sirolimus confers additional risk, relative to the potential improvement in maternal survival and maternal graft function/survival conferred by these drugs. Given the multiplicity of immunosuppressive regimens, only broad-based registry participation can provide the data needed to analyze such complex questions. Future analyses are directed at potential effects of these newer immunosuppressive regimens, not only from immediate exposure, but also from potential long-term exposures such as may occur from breastfeeding. As the registry study design allows for continuing contact between registry staff and recipients and their health care providers, efforts are in progress to analyze long-term outcomes of parent and child. Continued close collaboration among specialists will help to better identify potential pregnancy risks in these populations, especially as new immunosuppressive agents are developed.

Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation

The NTPR maintains an ongoing active database to study the safety of pregnancy in transplant recipients and currently includes the outcomes of more than 900 female recipients who became pregnant after their transplant and just over 700 male recipients who fathered one or more pregnancies after receiving a transplant. Analyses include the long-term follow-up of the recipient's graft status and their offspring. Successful pregnancy outcomes have been noted for each solid organ recipient group. The Registry includes information on 1,097 pregnancies in 716 kidney recipients, 187 pregnancies in 111 liver recipients, 56 pregnancies in 38 P/K recipients and smaller numbers for other organs and combinations of organs. There are periodic reports of recipients with graft dysfunction, rejection, or graft loss that may be related to pregnancy events, though the majority of outcomes reported to the NTPR appear favorable for parent and newborn. Organ-specific issues and comorbidities must also be considered in analyzing outcomes. The pregnancy issues that face recipients and caretakers with the current newer adjunctive therapies and newer immunosuppressive regimens require ongoing study. The potential risk of teratogenicity must be weighed against the potential risk of rejection when altering drug regimens before planned conceptions or in making dosage adjustments during pregnancy. Unplanned pregnancies present obvious concerns. Pregnancy safety has not been established for either MMF or sirolimus and all centers are encouraged to report pregnancies with exposures to these agents to the NTPR. Continuing analyses are directed at potential effects of the newer immunosuppressive regimens, not only to identify any risks to the pregnancy from immediate exposure, but also for potential postpartum exposures such as from breastfeeding. As the registry study design allows for continued contact, efforts continue to accrue long-term follow-up of both parent and child.

Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation

The NTPR maintains an ongoing database to study the outcomes of pregnancies in female transplant recipients as well as those pregnancies fathered by male transplant recipients. Recipients are entered into the database by completing. a single page questionnaire. There is steady follow-up of recipients and their offspring. While the majority of pregnancy outcomes have occurred in kidney recipients, data continue to accrue in the other types of organ recipients. KIDNEY: A small percentage of pregnancies in female kidney recipients are complicated by rejection with poorer outcomes with respect to both maternal graft function and their newborn. Other analyses this year focused on outcomes of recipients with systemic lupus erythematosus and those with multiple gestations. It was observed that recipients with systemic lupus erythematosus were able to maintain a pregnancy with outcomes that appear to be similar to other diagnoses. In an analysis of multiple gestations in female kidney recipients maintained on calcineurin inhibitors, no multiple gestations higher than triplets have been reported to the NTPR. Successful outcomes have been noted among these recipients. This does require continued surveillance, as there has been an increase in the number of multiple gestations in the general population with the use of adjunctive technologies. OTHER ORGANS: In analyzing outcomes in female liver recipients, no specific graft or newborn outcome differences have been noted when a comparison has been made between different caicineurin inhibitor regimens. Pregnancies in female pancreas-kidney recipients appear to be tolerated with respect to pancreas graft function with no diagnoses of gestational diabetes reported to the NTPR. Data continue to accrue among thoracic recipients. Poorer maternal survival postpartum in lung recipients may be related to higher risks inherent in this population and requires further experience and investigation. OTHER ISSUES: With the recent proliferation of newer immunosuppressive agents, a question that is raised is whether a regimen can be specifically designed with recipients of childbearing age in mind. Extensive data published on azathioprine and cyclosporine treated recipients suggests that while there is a pattern of prematurity among the newborn there has not been an increase in the incidence or pattern of specific malformations noted among the newborn. Less assurance can be given with newer agents such as sirolimus and MMF. Calcineurin inhibitor minimization or steroid withdrawal would require that other agents with less reproductive information be implemented. The unknown risk of teratogenicity must be balanced against the potential risk of rejection or graft dysfunction when deciding which agent to use during pregnancy. Through each of the organ recipient groups, there are sporadic cases of rejection, graft dysfunction, and graft deterioration. Birth defect patterns have not appeared to be specific to any specific regimen as yet. Two newborns with malformations have been noted among a limited series with MMF exposure, but other factors may also be at play. The use of MMF during pregnancy continues to be an unresolved issue in the transplant community. As yet, no one regimen has been identified as superior to another for use during pregnancy. Continued surveillance with the newer agents is necessary. Investigators have taken differing views regarding the safety of breastfeeding in the transplant recipient population, especially with regard to drug exposure to the infant. This issue remains unresolved and some transplant recipient mothers have chosen to breastfeed. Other factors for consideration are the potential long-term effects on offspring of transplant recipients. While there may not be specific structural defects noted at birth, more subtle effects on either immunologic or reproductive function may not manifest until later in life. Scott and his group in Utah have raised this issue with a case report and have initiated a study to focus on the next generation. The safety of pregnancy for parent and child remain the goals of the NTPR. Continued entries to the registry, especially in light of newer combinations of immunosuppressive agents, should assist in developing guidelines needed for management in this era of expanding immunosuppressive agents. All centers are encouraged to participate.

Crescentic glomerulonephritis and subepidermal blisters with autoantibodies to alpha5 and alpha6 chains of type IV collagen

We describe a novel autoimmune disease characterized by severe subepidermal bullous eruption and crescentic glomerulonephritis with autoantibodies directed against the noncollagenous domain of the alpha5 and alpha6 chains of type IV collagen. Biopsy of perilesional skin revealed a subepidermal blister with marked polymorphonuclear infiltrate with linear deposits of IgA and C3. Light microscopy of a kidney biopsy specimen revealed a crescentic glomerulonephritis, and immunofluorescence microscopy showed linear basement membrane staining for IgA (3+), C3 (1+), and IgG (1+). No electron-dense deposits were observed by transmission electron microscopy. The patient's autoantibodies reacted with normal human skin and kidney: IgA (3+) and IgG (1+) antibodies stained the basement membrane zones of skin, renal glomerulus, and some tubules. The identity of the target antigen was determined by immunochemical analyses of candidate antigens using the patient's autoantibodies. The patient's IgA and IgG autoantibodies reacted with a 185- to 190-kDa antigen from a human dermal extract that was distinguished from the other dermal or epidermal antigens, including the 145- to 290-kDa (type VII collagen) epidermolysis bullosa acquisita antigen, the 165- to 200-kDa alpha3 laminin mucous membrane cicatricial pemphigoid antigen, and the 230-kDa and the 180-kDa bullous pemphigoid antigens. Patient's IgA and IgG autoantibodies further reacted with the alpha5(IV) and weakly with the alpha6(IV) chains of type IV collagen by Western blot and ELISA. This report expands the repertoire of bullous skin disorders and provides an explanation for the association of anti-type IV collagen autoantibodies and glomerulonephritis with subepidermal blisters.

Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation

The NTPR continues to maintain an ongoing active database as a resource for health professionals counseling recipients regarding pregnancy and for recipients themselves to contact the registry and request information. This includes female transplant recipients as well as male recipients who father pregnancies. Recipients who consent are entered into a database; analyses are ongoing, including long-term follow-up of the recipient, the graft and the offspring. The safety of pregnancy for parent and child remains the goal of the registry. Guidelines for counseling recipients proposed in 1976 remain applicable. Recipients should be in general good health and graft function should be stable and ideally rejection free. Comorbid conditions should be well controlled, especially hypertension and diabetes. While these counseling guidelines were formulated for kidney recipients, they may be extrapolated for other organ recipients. Analyses this year included pregnancy outcomes of recipients on newer agents, MMF and sirolimus. It remains unclear whether these adjunctive therapies should be altered for pregnancy. The balance of immunosuppression and the prevention of rejection need to be weighed against the potential for teratogenicity when counseling these recipients inquiring about pregnancy. Although there are periodic reports of recipients with graft dysfunction, rejection or graft loss possibly related to pregnancy events throughout all the organ groups, whether transplanted as adults or as pediatric patients, the majority of pregnancy outcomes reported to the NTPR appear favorable for parent and newborn. Whether recipients should breastfeed remains controversial. Recent reports in the literature as well as NTPR data appear favorable. This represents the last report from our initial established location at Thomas Jefferson University. In January of this year, the registry moved to Temple University School of Medicine, Department of Surgery, Philadelphia, PA. The NTPR remains committed to investigating outcomes of pregnancies reported by centers or self-referrals nationwide. Some of the active issues for the upcoming year include the potential for teratogenicity with combinations of newer agents, incidence of viral hepatitis, risk assessment for pregnancy in female lung recipients, and long-term maternal and pediatric follow-up.

Report from the national transplantation pregnancy registry (NTPR): outcomes of pregnancy after transplantation

The NTPR continues to analyze the safety of pregnancy in female transplant recipients as well as outcomes of pregnancies fathered by male transplant recipients. With regard to female recipients, pregnancy does not appear to adversely affect graft function, when the function of the transplanted graft is stable prior to pregnancy. A small percentage of recipients with each transplanted organ develops rejection, graft dysfunction or graft loss. These events may occur in recipients with pre-pregnancy graft dysfunction or on occasion, occur unpredictably. Female cyclosporine-treated kidney recipients with both shorter and longer intervals from transplant to conception have been analyzed, with favorable outcomes noted. It appears sensible to continue to advise recipients to wait one to 2 years after transplant to allow for stable graft function as well as stabilization of immunosuppressive medications. However, given that favorable outcomes can occur with either shorter or longer intervals, these recipients need to be counseled and followed on a case-by-case basis. Newer agents and more potent regimens are under continued surveillance. Two cases with structural malformations have been noted in female recipient offspring with exposure to MMF during pregnancy. Data remain limited and are insufficient to determine a specific malformation incidence. The risk of graft rejection as well as graft dysfunction must be weighed against the risk of potential teratogenicity when maintaining female recipients on MMF during pregnancy. For male recipients maintained on MMF, there have been no patterns of problems noted in their offspring. The structural malformation incidence in newborn of cyclosporine-treated recipients is in the range expected for the general population without any specific predominance of malformations. It remains to be seen whether or not any specific pattern of problems will become apparent in the newborn with newer regimens. Controversy surrounding breastfeeding continues, although it has become an option that some recipients choose to consider. Data have accrued in liver, heart, pancreas-kidney and lung recipients. Among lung recipients, there appears to be poorer maternal survival postpartum, which may be related to pregnancy or may be inherent in this population. Continued entries to the registry, especially in light of newer combinations of immunosuppressive agents, should help to provide the guidelines for management. All centers are encouraged to participate.

The initial attitudes of patients toward longer maintenance hemodialysis

Longer hemodialysis (HD) as practiced in parts of Europe and Japan may improve both blood pressure control and patient survival. Nevertheless, in the USA, the trend has been to shorten dialysis time using larger dialyzers and increased blood flows. Many patients find the notion of shorter dialysis enticing. Most are unaware ofthe potential benefits of longer dialysis. We surveyed stable chronic HD patients in an urban area, the vast majority of whom received conventional 4-hour treatments, regarding their attitude toward extending their dialysis time to 5 hours. They were informed that longer dialysis has been associated with better blood pressure control and improved survival. One hundred and sixteen patients completed questionnaires during a single dialysis session. Forty-six (40%) agreed to extended dialysis while 70 (60%) did not. There was no difference between the groups with respect to the following variables: age, race, etiology of ESRD, time on dialysis, marital status, number of children at home, number residing in the household, education, or employment status. Male gender was associated with a positive response (p = 0.03). Various suggested and spontaneous reasons were given for a negative response.

CONCLUSION

With minimally detailed information, 4 in 10 patients were willing to extend their treatment time to 5 hours in the hope of improving morbidity and survival. No sociodemographic variable except gender was associated with a positive response.

Association of IgA nephropathy with Clostridium difficile colitis

Immunoglobulin A (IgA) nephropathy, the most common cause of glomerulonephritis worldwide, is usually idiopathic in origin and renal limited. Secondary IgA nephropathy has been associated with systemic disease, including such gastrointestinal tract disturbances as celiac sprue and inflammatory bowel disease. We describe gross hematuria and reversible acute renal failure from IgA nephropathy in a patient with cephalosporin-induced Clostridium difficile colitis. In addition to mesangial IgA and C3 deposition, renal histological examination showed glomerular bleeding, intratubular red blood cell casts, and acute tubular necrosis. To the best of our knowledge, this is the first report of an association between IgA nephropathy and C difficile colitis.

Association of IgA nephropathy with Clostridium difficile colitis

Immunoglobulin A (IgA) nephropathy, the most common cause of glomerulonephritis worldwide, is usually idiopathic in origin and renal limited. Secondary IgA nephropathy has been associated with systemic disease, including such gastrointestinal tract disturbances as celiac sprue and inflammatory bowel disease. We describe gross hematuria and reversible acute renal failure from IgA nephropathy in a patient with cephalosporin-induced Clostridium difficile colitis. In addition to mesangial IgA and C3 deposition, renal histological examination showed glomerular bleeding, intratubular red blood cell casts, and acute tubular necrosis. To the best of our knowledge, this is the first report of an association between IgA nephropathy and C difficile colitis.

A 6-month study of low-dose recombinant human erythropoietin alone and in combination with androgens for the treatment of anemia in chronic hemodialysis patients

Two previous short-term studies (12 weeks and up to 16 weeks) that used androgens to supplement recombinant human erythropoietin (rHuEPO) for the treatment of the anemia associated with end-stage renal disease showed divergent results. Both studies were limited by their brief duration, since the hematopoietic effect of androgens does not peak until 5 months. Therefore, we conducted a 6-month, prospective, randomized trial comparing low-dose rHuEPO alone and in combination with androgens for the treatment of the anemia of end-stage renal failure. Nineteen anemic chronic hemodialysis patients were randomized into two groups. Group A (n = 10) received 1,500 U rHuEPO intravenously three times a week for 26 weeks. Group B (n = 9) received the same dose of rHuEPO plus nandrolone decanoate 100 mg intramuscularly weekly. Baseline transferrin saturation, serum ferritin, intact serum parathyroid hormone, plasma aluminum, and hematocrit levels were not significantly different between the groups. At study completion, both groups showed a significant increase in mean hematocrit compared with baseline (group A: 24.8% +/- 1.4% to 28.3% +/- 2.8%, P = 0.003; group B: 25.1% +/- 1.5% to 33.2% +/- 4.5%, P = 0.001). The increase in hematocrit in the rHuEPO plus androgen-treated group was statistically greater than in the rHuEPO-alone group (8.2% +/- 4.4% v 3.5% +/- 2.8%; P = 0.012). With the exception of mild discomfort at the injection site, there were no significant side effects from nandrolone. We conclude that the combination of low-dose rHuEPO and nandrolone decanoate is effective treatment for the anemia of end-stage renal failure.

Coexistence of atheroemboli and minimal-change disease

We report the first case of coexistent cholesterol emboli and minimal-change disease in an elderly individual with acute renal failure and the nephrotic syndrome. Renal insufficiency heavy proteinuria improved rapidly with oral steroids.

National Transplantation Pregnancy Registry: report on outcomes in cyclosporine-treated female kidney transplant recipients with an interval from transplant to pregnancy of greater than five years

Successful renal transplantation enables previously infertile females to conceive and carry a pregnancy. Much of the reported data on posttransplantation pregnancy accrued before the advent of cyclosporine, when steroids and azathioprine were the mainstays of maintenance immunosuppression. One factor affecting pregnancy outcome in kidney recipients is the length of time from transplantation to conception or transplant interval. It has been recommended that patients wait at least 2 years posttransplantation to conceive, as transplant intervals of shorter duration have had less favorable outcomes. Some have suggested that extended transplant intervals (> 5 years) paradoxically result in adverse outcomes. We have extracted data on cyclosporine-treated recipients with transplant intervals longer than 5 years from the National Transplantation Pregnancy Registry, and report 17 pregnancies from 15 recipients (transplant interval, 5.9 +/- 0.9 years). There were 13 live births (76.5%) and four spontaneous abortions (23.5%). The mean gestational age was 37.7 +/- 2.04 weeks and mean birth weight was 2,753 +/- 679 g. Prematurity occurred in 30.8%, low birth weight in 15.4%, very low birth weight in 7.7%, and neonatal complications in 15.4%. There were no maternal or neonatal deaths. The mean serum creatinine before pregnancy was 1.31 mg/dL, and there was no significant change during or after pregnancy. There were no rejections during or up to 3 months postpartum. Graft survival at 2 years was 100%. We conclude that most pregnancy outcomes in cyclosporine-treated recipients with transplant intervals greater than 5 years are favorable for the newborn, recipient, and graft.

A retrospective analysis of the effect of indomethacin on adverse reactions to orthoclone OKT3 in the therapy of acute renal allograft rejection

Orthoclone OKT3 (Ortho Biotech Inc, Raritan, NJ) is a potent immunosuppressive agent effective in the therapy of acute renal allograft rejection. Following the first one or two doses, patients often exhibit a "flu-like" illness ascribed to OKT3-induced release of cytokines. Systemic reactions resulting from the cytokines include pyrexia, pulmonary edema, bronchospasm, photophobia, headache, hypotension, rigors, hypertension, gastrointestinal disturbances, and arthralgias/myalgias. The cyclooxygenase inhibitor indomethacin has been shown to ameliorate the pyrexia associated with OKT3 administration. We conducted a retrospective analysis with the purposes of (1) confirming that indomethacin reduces pyrexia and (2) determining the effect of indomethacin on the other aforementioned adverse side effects. Group 1 patients (n = 28) received indomethacin during the initial 48 hours of OKT3 antirejection therapy. Group 2 patients (n = 28) received OKT3 without indomethacin. The incidence of fever (P < 0.0001), headache (P < 0.030), and gastrointestinal disturbances (P < 0.030), and the number of adverse effects (P < 0.0001) were significantly less in the indomethacin-treated group. There were no differences between the groups in pre- and post-OKT3 serum creatinine levels. The indomethacin was well tolerated. We conclude that the widely available and relatively inexpensive cyclooxygenase inhibitor indomethacin safely and significantly reduces adverse effects associated with OKT3 therapy of acute renal allograft rejection.

Ranitidine-induced acute interstitial nephritis with epithelial cell foot process fusion

Although acute interstitial nephritis has been well described with the histamine H2-receptor antagonist cimetidine, we found only one previous case report of ranitidine-induced interstitial nephritis in the literature. We describe an additional patient who developed acute interstitial nephritis after taking ranitidine. Electron microscopy showed focal fusion of the epithelial cell foot processes that was not described in the previous report of ranitidine-induced interstitial nephritis.

Serum bactericidal activity for Yersinia enterocolitica in hemodialysis patients: effects of iron overload and deferoxamine

Human serum has been shown to be bactericidal for most strains of Yersinia enterocolitica. Systemic Y enterocolitica infections have been reported in iron-overloaded hemodialysis patients treated with deferoxamine. Both iron and deferoxamine are known to enhance the growth of Y enterocolitica. We inoculated sera from 12 hemodialysis patients whose serum ferritin levels ranged from 26 to 6,855 micrograms/mL (ng/mL), as well as three controls, with Yersinia organisms. After latencies of 0 to 24 hours, inoculated sera were then plated on blood agar. Bactericidal activity was demonstrated in all sera and the degree of activity did not correlate with ferritin levels. Bactericidal activity was also demonstrated in sera from three deferoxamine treated patients. We conclude that in vitro, sera of end-stage renal failure patients, with and without iron overload, are as bactericidal as control sera for Y enterocolitica and that deferoxamine therapy does not interfere with that bactericidal activity.