PREGNANCY POST-RENAL TRANSPLANT

Pregnancy Post-Renal Transplant

Balasubramaniam

Chief of Nephrology, Kauvery Hospital, Chennai

All is well that ends well!

A 24-years-aged female, presented to us with End Stage Kidney Disease 3 years before for which she underwent a live-related renal transplantation. Her renal donor was her mother. She had uneventful post-transplant period and was on triple immune suppression that included tacrolimus, mycophenolate and prednisolone,

Her kidney function remained normal post renal transplant with well-controlled blood pressure with a single anti-hypertensive drug (Amlodepine), and she had no proteinuria.

One-year post-renal transplantation her family asked about getting her married, and after a few counselling sessions with her family and with her spouse, she got married 1 year after her transplantation.

Understandably the question of pregnancy came up and we had to change her MMF to azathioprine and allowed her to plan for her pregnancy; she delivered a normal female child 2 weeks ago!

Challenges in post-renal transplant pregnancy

How common is pregnancy post-transplantation?

ESRD causes infertility due to hormonal changes with renal failure and due to impaired milieu interior. Successful renal transplantation normalizes these abnormalities and post-transplant pregnancy is increasingly common [1]. Pre-natal counselling regarding contraception during the initial periods post-transplantation is important. Maternal and fetal risks, immune suppression modification, need for close monitoring are important counselling aspects.

When can a post-transplant woman could become pregnant?

It is advisable to postpone pregnancy by 1-2 years post-transplant. It is ideal to have serum creatinine < 1.4 mg/dl, with well controlled blood pressure and proteinuria < 500 mg/day.

What are the maternal risks during pregnancy post transplantation?

Serum creatinine >1.4 mg/dl, proteinuria > 500 mg/ day at the time of conception are associated with increased incidence of graft loss. The risk of pre-eclampsia (24-38% higher), eclampsia, graft rejection, hyperfiltration related renal injury and urinary tract infections are common in pregnant mother. Risk of Cesarean section is 5 times higher compared to general population.

What precautions in immune suppression management to be considered during pregnancy?

Most immune suppressive drugs cross the placenta and are fortunately found to be safe to use during pregnancy. The commonly used drugs including cyclosporin, tacrolimus, azathioprine and steroids are reasonably safe to use. MMF is absolutely contra indicated as it is associated with increased risks of fetal congenital abnormalities and, pre-term births. Limited data is available regarding m TOR inhibitors (sirolimus/everolimus) and some case reports of successful pregnancies are reported with these drugs [2].

What are the fetal complications in post-transplant pregnancy?

Increased risks for miscarriages, pre-term deliveries, low birth weight babies, intra uterine growth retardation and congenital malformations are reported in children.

Is breastfeeding safe in post-transplant pregnancy?

Though the regular immune suppressive drugs are to some extent expressed in breast milk, no significant adverse effects are reported. So, these drugs are not contra indicated for breast feeding the child. MMF, sirolimus and Everolimus are contra indicated [3].

Conclusion

Pregnancy in a post-transplant woman is reported in significant numbers globally. Good graft function with well controlled blood pressure and insignificant proteinuria are basic requirements for a woman to become pregnant with less chances of adverse graft outcomes. Though the risk of maternal and fetal complications is higher compared to general population, careful monitoring and management results in normal outcomes. Modification of immune suppression is necessary and breast feeding is reasonably safe.

References

Kent R, et al. Pregnancy and kidney transplantation. In: Sachdeva, M., Miller, I. (eds) Obstetric and Gynecologic Nephrology. 2020.
Saurez, MLG. Pregnancy in Kidney Transplant Recipients. Adv Chronic Kidney Dis. 2020;27(6):486-498.
McKay. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005;5(7):1592-1599.

Dr. R. Balasubramaniyam

Chief Nephrologist

PREGNANCY POST-RENAL TRANSPLANT