Pregnancy after deceased donor vs living donor kidney transplant: associated obstetric and graft outcomes

Abstract

Outside of pregnancy, deceased donor kidney transplant recipients experience worse graft and overall survival compared to living donor kidney transplant recipients. In pregnancy, it is unknown whether the type of donor graft modifies either graft health in the peripartum period or pregnancy outcomes. The objective of this study was to define characteristics and outcomes in pregnancy based on donor type in kidney transplant recipients. Retrospective cohort study of adult kidney transplant recipients who received their graft between 2000-2019 with a subsequent pregnancy enrolled in the Transplant Pregnancy Registry International. The primary outcome was graft loss within 2 years of delivery. Secondary outcomes included severe maternal morbidity and neonatal composite morbidity. Univariate, multivariable logistic regression, and Cox proportional-hazards models were constructed for statistical analysis, with living unrelated donor recipients as the referent. 638 pregnancy outcomes after kidney transplant met our inclusion criteria. Of these, 168 (26.3%) received a graft from a deceased donor (DD), 310 (48.6%) from a living related donor (LR), and 160 (25.1%) from a living unrelated donor (LU). DD recipients were more likely to be nulliparous, have an unplanned pregnancy, and self-identify as non-white. DD recipients were more likely to experience urinary tract infections (DD: 21.8%; LR: 10.1%; LU: 20.6%) (p=0.018). Severe maternal morbidity did not differ by donor type (DD: 3.4%; LR: 2.8%; LU: 7.2%), nor did neonatal composite morbidity (DD: 8.4%, LR: 17.1%, LU: 14.4%). DD transplant was associated with graft loss within 2 years of delivery (DD: 6.7%, LR: 3.7%, LU: 1.3%, aOR: 7.52 [1.53, 60.8]) and long-term graft loss from transplant (aHR: 2.08, [1.10, 3.95]). While our study demonstrates an association between deceased donor transplant and graft loss after pregnancy, it does not provide evidence that pregnancy itself causes graft loss. Deceased donor kidney transplant recipients should not be discouraged from pursuing pregnancy based on their donor type, but these patients should undergo preconception counseling with a discussion of their individualized obstetric and graft risks, close intrapartum monitoring for infection and hypertensive disease, and continued surveillance for at least 2 years postpartum with a multidisciplinary obstetrics and transplant team.