Dutch Cohort Study Research Articles

MA05.08 Follow-Up after First-Line Nivolumab Plus Ipilimumab in Patients with Pleural Mesothelioma: A Real-World Dutch Cohort Study (FLORA-Study)

MA05.08 Follow-Up after First-Line Nivolumab Plus Ipilimumab in Patients with Pleural Mesothelioma: A Real-World Dutch Cohort Study (FLORA-Study)

Sex-related differences in the clinical course of aortic root and ascending aortic aneurysms: the DisSEXion Study.

To explore male-female differences in aneurysm growth and clinical outcomes in a two-centre retrospective Dutch cohort study of adult patients with ascending aortic aneurysm (AscAA). Adult patients in whom imaging of an AscAA (root and/or ascending: ≥40 mm) was performed between 2007 and 2022 were included. Aneurysm growth was analysed using repeated measurements at the sinuses of Valsalva (SoV) and tubular ascending aorta. Male-female differences were explored in presentation, aneurysm characteristics, treatment strategy, survival, and clinical outcomes. One thousand eight hundred and fifty-eight patients were included (31.6% female). Median age at diagnosis was 65.4 years (interquartile range: 53.4-71.7) for females and 59.0 years (interquartile range: 49.3-68.0) for males (P < .001). At diagnosis, females more often had tubular ascending aortic involvement (75.5% vs. 70.2%; P = .030) while males more often had SoV involvement (42.8% vs. 21.6%; P < .001). Maximum absolute aortic diameter, at any location, at diagnosis did not differ between females (45.0 mm) and males (46.5 mm; P = .388). In females, tubular ascending growth was faster (P < .001), whereas in males, SoV growth was faster (P = .005), corrected for covariates. Unadjusted 10-year survival was 72.5% [95% confidence interval (CI) 67.8%-77.6%] for females and 78.3% (95% CI 75.3%-81.3%) for males (P = .010). Twenty-three type A dissections occurred, with an incidence rate of 8.2/1000 patient-years (95% CI 4.4-14.1) in females and 2.4/1000 patient-years (95% CI 1.2-4.5) in males [incidence rate ratio females/males: 3.4 (95% CI 1.5-8.0; P = .004)]. In patients having entered a diagnostic programme, involvement of aortic segments and age- and segment-related growth patterns differ between women and men with AscAA, particularly at an older age. Unravelling of these intertwined observations will provide a deeper understanding of AscAA progression and outcome in women and men and can be used as an evidence base for patient-tailored clinical guideline development.

Impact of clinical and treatment characteristics on HR-QoL in patients with prolactinoma - cross-sectional analysis of a dutch multicenter prospective cohort study

Impact of clinical and treatment characteristics on HR-QoL in patients with prolactinoma - cross-sectional analysis of a dutch multicenter prospective cohort study

164 Enteropathy in Patients with Common Variable Immunodeficiency: A Dutch Cohort Study

164 Enteropathy in Patients with Common Variable Immunodeficiency: A Dutch Cohort Study

Can skills differences explain the gap in track recommendation by socio-economic status?

ABSTRACT Tracking early in the school career can significantly influence a student's educational path. Using data from a Dutch cohort study linked with administrative records, we examine the gap in track recommendation between students from different socio-economic groups at the end of primary school. We find that students whose parents are not tertiary educated receive significantly lower recommendations on average. A decomposition of the total difference in track recommendations shows that differences in cognitive and non-cognitive skills can explain around 57% of the gap. Adding additional information about the family, school, and place of residence reduces the unexplained gap to 28%.

Diagnostic accuracy of MRI, CT, and [18F]FDG-PET-CT in detecting lymph node metastases in clinically early-stage cervical cancer — a nationwide Dutch cohort study

ObjectivesImaging is increasingly used to assess lymph node involvement in clinically early-stage cervical cancer. This retrospective study aimed to evaluate the diagnostic accuracy of MRI, CT, and [18F]FDG-PET-CT.MethodsWomen with International Federation of Gynaecology and Obstetrics (FIGO) 2009 stage IA2-IIA cervical cancer and pretreatment imaging between 2009 and 2017 were selected from the Netherlands Cancer Registry. Patient-based and region-based (i.e. pelvic and common iliac) nodal status was extracted from radiology reports. Pathology results were considered the reference standard for calculating accuracy indices. Multiple imputation was used for missing pathology to limit verification bias risk.ResultsNodal assessment was performed in 1676 patients with MRI, 926 with CT, and 379 with [18F]FDG-PET-CT, with suspicious nodes detected in 17%, 16%, and 48%, respectively. [18F]FDG-PET-CT was used to confirm MRI/CT results in 95% of patients. Pathology results were imputed for 30% of patients. [18F]FDG-PET-CT outperformed MRI and CT in detecting patient-based nodal metastases with sensitivities of 80%, 48%, and 40%, and AUCs of 0.814, 0.706, and 0.667, respectively, but not in specificity: 79%, 92%, and 92%. Region-based analyses showed similar indices in the pelvic region, but worse performance in the common iliac region with AUCs of 0.575, 0.554, and 0.517, respectively.Conclusions[18F]FDG-PET-CT outperformed MRI and CT in detecting nodal metastases, which may be related to its use as a verification modality. However, MRI and CT had the highest specificity. As MRI is generally performed routinely to assess local and regional spread of cervical cancer, [18F]FDG-PET-CT can be used to confirm suspicious nodes.Critical relevance statementAccurate assessment of the nodal status in clinically early-stage cervical cancer is essential for tumour staging, treatment decision making and prognosis.Key points• The accuracy of MRI, CT or [18F]FDG-PET-CT for nodal staging in early cervical cancer is a subject of discussion.• Overall, [18F]FDG-PET-CT outperformed MRI, followed by CT, when used as a verification modality.• Staging with MRI and the addition of [18F]FDG-PET-CT to verify high-risk cases seems to be a good approach.Graphical

Incidence, clinical management and prognosis of patients with small intestinal adenocarcinomas from 1999 through 2019: A nationwide Dutch cohort study

BackgroundSmall intestinal adenocarcinomas (SIAs) are rare. Hence, randomized controlled trials are lacking and understanding of the disease features is limited. This nationwide cohort investigates incidence, treatment and prognosis of SIA patients, to improve disease outcome. Patients and methodsData of 2697 SIA patients diagnosed from January 1999 through December 2019 were retrieved from the Netherlands Cancer Registry and Pathology Archive. Incidence was calculated using the revised European Standardized Rate. The influence of patient and tumor characteristics on overall survival (OS) was studied using survival analyses. ResultsThe age-standardized incidence rate almost doubled from 0.58 to 1.06 per 100,000 person-years, exclusively caused by an increase in duodenal adenocarcinomas. OS did not improve over time. Independent factors for a better OS were a younger age, jejunal tumors, Lynch syndrome and systemic therapy. Only 13.8% of resected patients was treated with adjuvant chemotherapy, which improved OS compared to surgery alone in stage III disease (HR 0.47 (0.35–0.61)), but not in the limited group of deficient mismatch repair (MMR) patients (n = 53, HR 0.93 (0.25–3.47)). In the first-line setting, CAPOX was associated with improved OS compared to FOLFOX (HR 0.51 (0.36–0.72)). For oligometastatic patients, a metastasectomy significantly improved OS (HR 0.54 (0.36–0.80)). ConclusionsThe incidence of SIAs almost doubled in the past 20 years, with no improvement in OS. This retrospective non-randomized study suggests the use of adjuvant chemotherapy for stage III disease and first-line CAPOX for metastatic patients. For selected oligometastatic patients, a metastasectomy may be considered. MMR-status testing could aid in clinical decision-making.

The ABOARD Cohort Panel: public involvement in a Dutch Cohort study on a personalized medicine approach for Alzheimer’s disease

AbstractBackgroundABOARD is a Dutch public‐private partnership aiming for a personalized medicine approach for Alzheimer’s disease. Within this project, the ABOARD Cohort is initiated: a national prospective data infrastructure with the objective to study the AD disease trajectory using PROMS and linked clinical data. The ABOARD Cohort Panel has been installed to provide advice on the design, execution, and direction of the study. By incorporating the perspective of potential participants the meaningfulness and accessibility of the ABOARD Cohort is ensured.MethodRecruitment for the panel has been initiated by the Dutch Brain Foundation via social media and newsletters, and approximately 300 people responded with potential interest. To further inform them, we hosted a webinar explaining the ABOARD Cohort Panel. Hereafter, respondents received an official Panel invitation and initial survey (including principles for collaboration), resulting in 59 people signing up as panellists.ResultPanel members are on average 62 years old, 78% is female, 96% has no migration background, and 52% participated in a panel before. Panellists vary in education level and geographic distribution. The majority has a personal interest in dementia (64%) and/or friends/family with dementia (62%). When asked how they would like to be involved, they indicated wanting to be involved in online questionnaires (100%), online focus groups (56%), and in‐person focus groups (36%). The majority preferred monthly questionnaires (50%) with a duration of 10‐20 minutes (52%). In the first months, panellists provided feedback in online surveys on the ABOARD Cohort information letter and informed consent form. They considered these lengthy, too difficult, and raising questions. An in‐depth live session was held with panellists to test subsequent adjustments, resulting in higher agreement rates on the informed consent procedure of the ABOARD Cohort. Panellists also advised on the communication strategy of the national ABOARD Cohort campaign, which is currently being implemented. In the coming months, panel members will test the usability of the ABOARD Cohort portal and an online cognitive test and advice on dissemination and variables that are being collected.ConclusionThe ABOARD Cohort Panel incorporates the perspective of potential participants and aims to ensure the meaningfulness and accessibility of the ABOARD Cohort.

The impact of induced earthquakes on mental health: evidence from the Dutch Lifelines Cohort Study

Abstract Background A growing body of literature demonstrates that exposure to events, such as natural disasters, accidents, or adverse life events, may increase the risk of physical and psychological distress. Despite this understanding, little is known about the health consequences of consistent exposure to human-made crises. To address this issue, we examine the long-term health effects of mining-induced earthquakes in the Northern Netherlands and study the heterogeneity of the effect across socioeconomic status (SES). Methods Large-scale individual health data is from the Dutch Lifelines biobank and cohort study with 148,700 participants from the Northern Netherlands. Earthquake data is from Royal Netherlands Meteorological Institute. The main health outcomes are housing-related stress, depression, anxiety, and self-assessed health. The key independent variable is accumulated peak ground velocity. We use an individual-level fixed effects model to assess the health effects of induced earthquakes by controlling individual heterogeneity, especially migration preference. Further, we add the interaction terms of accumulated PGV and education level into the regression model to analyze the different effects of earthquakes across SES. Results We find an association between living in high-exposure areas and housing-related stress. The results also show that for each additional noticeable earthquake (PGV&amp;gt;0.5 cm/s), the probability of getting anxiety increases by 1.04% on average. Moreover, the number of noticeable earthquakes (PGV&amp;gt;0.5 cm/s) has an adverse impact on self-assessed health. After adding the interaction terms, considerable health effects disparities were observed between SES, with the highest health effects of earthquakes in the lowest SES groups. Conclusions Our results indicate that the long-run effects of sequences of small shocks are more significant than previously believed. The low SES group was the most vulnerable population to induced earthquakes. Key messages • This paper aims to estimate the causal effects of mining-induced earthquakes on health by employing large-scale panel data from the Lifelines biobank and cohort study in the Northern Netherlands. • Our findings suggest that exposure to repeated earthquakes has a negative effect on housing-related stress, anxiety, and self-rated health.

Associating night-shift work with lifetime use of sleep medication and sleep quality in a cohort of female nurses.

Night-shift workers often sleep at moments, not in sync with their circadian rhythm. Though the acute effects of night-shift work on sleep quality directly after a night shift are well described, less is known about the chronic effects of night-shift work on sleep. We associated ever-working night shifts and recently working night shifts (<4 wk) with lifetime use of sleep medication and melatonin, self-reported average sleep duration and sleep quality over the 4 wk preceding inclusion (measured using the Medical Outcomes Study Sleep scale). We explored trends in sleep outcomes with average frequency of night shifts per week, tenure of night-shift works in years, and time since last performed night work. This research was conducted within the Nightingale study which is a Dutch cohort study of 59,947 female registered nurses aged 18 to 65. Working night shifts was not associated with self-reported nonoptimal sleep length and sleep quality. However, we observed higher odds of lifetime use of sleep medication for nurses who ever-worked night shifts (OR 1.24; 95% CI 1.13, 1.35) and who recently worked night shifts (OR 1.13; 95% CI 1.05, 1.22); with night-shift work frequency and tenure being associated with lifetime use of sleep medication (P-value for trend < 0.001 for both). Odds for melatonin use were elevated for nurses who ever worked night shifts (OR 1.55; 95% CI 1.40, 1.71) and recently worked night shifts (OR 1.72; 95% CI 1.59, 1,86). The findings of this study have practical implications for healthcare organizations that employ nurses working night shifts. The observed associations between night-shift work and increased lifetime use of prescribed sleep medication and melatonin highlight the need for targeted support and interventions to address the potential long-term sleep problems faced by these nurses.

OP02_6. Nationwide pregnancy outcomes after kidney transplantation and prediction of adverse pregnancy outcomes: A Dutch cohort study

OP02_6. Nationwide pregnancy outcomes after kidney transplantation and prediction of adverse pregnancy outcomes: A Dutch cohort study

Understanding Health-Related Quality of Life in Kidney Transplant Recipients: The Role of Symptom Experience and Illness Perceptions.

The purpose of our article is to investigate the impact of symptom experience on health related quality of life (HRQOL) in kidney transplant recipients (KTRs) and whether illness perceptions mediated this impact. Symptom experience, illness perceptions, and HRQOL were measured at transplantation and 6weeks after transplantation in KTRs in an ongoing Dutch cohort study. Multivariable linear regression models were used for the analysis. 90 KTRs were analyzed. Fatigue and lack of energy were the most prevalent and burdensome symptoms at transplantation. Mental HRQOL at 6weeks after transplantation was comparable to that of the general Dutch population (mean [standard deviation, SD]: 49.9 [10.7]) versus 50.2 [9.2]), while physical HRQOL was significantly lower (38.9 [9.1] versus 50.6 [9.2]). Experiencing more symptoms was associated with lower physical and mental HRQOL, and the corresponding HRQOL reduced by -0.15 (95%CI, -0.31; 0.02) and -0.23 (95%CI, -0.42; -0.04) with each additional symptom. The identified mediation effect suggests that worse symptom experiences could cause more unhelpful illness perceptions and consequently lead to lower HRQOL. Illness perceptions may explain the negative impact of symptom experience on HRQOL. Future studies at later stages after kidney transplantation are needed to further explore the mediation effect of illness perceptions and guide clinical practice to improve HRQOL.

Artificial intelligence-based diagnosis of asbestosis: analysis of a database with applicants for asbestosis state aid

ObjectivesIn many countries, workers who developed asbestosis due to their occupation are eligible for government support. Based on the results of clinical examination, a team of pulmonologists determine the eligibility of patients to these programs. In this Dutch cohort study, we aim to demonstrate the potential role of an artificial intelligence (AI)-based system for automated, standardized, and cost-effective evaluation of applications for asbestosis patients.MethodsA dataset of n = 523 suspected asbestosis cases/applications from across the Netherlands was retrospectively collected. Each case/application was reviewed, and based on the criteria, a panel of three pulmonologists would determine eligibility for government support. An AI system is proposed, which uses thoracic CT images as input, and predicts the assessment of the clinical panel. Alongside imaging, we evaluated the added value of lung function parameters.ResultsThe proposed AI algorithm reached an AUC of 0.87 (p < 0.001) in the prediction of accepted versus rejected applications. Diffusion capacity (DLCO) also showed comparable predictive value (AUC = 0.85, p < 0.001), with little correlation between the two parameters (r-squared = 0.22, p < 0.001). The combination of the imaging AI score and DLCO achieved superior performance (AUC = 0.95, p < 0.001). Interobserver variability between pulmonologists on the panel was estimated at alpha = 0.65 (Krippendorff’s alpha).ConclusionWe developed an AI system to support the clinical decision-making process for the application to the government support for asbestosis. A multicenter prospective validation study is currently ongoing to examine the added value and reliability of this system alongside the clinic panel.Key Points• Artificial intelligence can detect imaging patterns of asbestosis in CT scans in a cohort of patients applying for state aid.• Combining the AI prediction with the diffusing lung function parameter reaches the highest diagnostic performance.• Specific cases with fibrosis but no asbestosis were correctly classified, suggesting robustness of the AI system, which is currently under prospective validation.

Biomarker concordance between primary colorectal cancer and ovarian metastases: a Dutch cohort study.

The genetic characteristics and mismatch repair (MMR) status of the primary tumor and corresponding metastases in colorectal cancer (CRC) are generally considered to be highly concordant. This implies that either the primary or metastatic tumor can be used for testing gene mutation and MMR status. However, whether this is also true for CRC and their ovarian metastases is currently unknown. Ovarian metastases generally show a poorer response to systemic therapy compared to other metastatic sites. Differences in biomarker status between primary CRC and ovarian metastases could possibly explain this difference in therapy response. The study cohort was selected from CRC patients treated in two Dutch hospitals. Eligible patients with CRC and ovarian metastasis who were surgically treated between 2011 and 2018 were included. CRC and corresponding ovarian metastatic tissues were paired. Gene mutation status was established using next-generation sequencing, while the MMR status was established using either immunohistochemistry or microsatellite instability analysis. Matched samples of CRC and ovarian metastasis from 26 patients were available for analysis. A biomarker concordance of 100% was detected. Complete biomarker concordance was found between MMR proficient CRC and their matching ovarian metastasis. Biomarker testing of MMR proficient CRC tissue appears to be sufficient, and additional testing of metastatic ovarian tissue is not necessary. Differences in therapy response between ovarian metastases and other metastases from CRC are thus unlikely to be caused by differences in the genetic status.

Efficacy and safety of dupilumab as add-on therapy for patients with severe asthma: A real-world Dutch cohort study

BackgroundDupilumab as add-on treatment for severe uncontrolled asthma (SA) has shown to be effective and safe by phase-III-trials. Real-world data on clinical efficacy and safety is limited. ObjectiveWe aim to investigate the efficacy and safety of dupilumab as add-on therapy for SA in a real-world cohort. Material and methodsThe primary endpoint was annually exacerbation-rate (AER). Secondary outcomes were maintenance oral corticosteroid (mOCS) dependency, asthma control (ACQ-5), pulmonary function (FEV1), quality of life (AQLQ) and frequency of reported adverse events (AEs). ResultsOverall, 148 patients were included. Median AER [IQR] reduced from 4.00 [2.00–5.00] at baseline to 1.00 [0.00–2.00] at 12 months (p < 0.001). mOCS-dependency reduced from 39.9% of the patients at baseline, to 20.3% at 6 months and to 14.9% at 12 months (p < 0.001). Median ACQ improved from 3.00 [2.00–3.80] at baseline to 1.80 [0.60–2.95] after 6 months and to 1.40 [0.20–2.60] after 12 months (p < 0.001). Median FEV1 (L) improved from 2.21 [1.58–2.85] to 2.50 [2.00–3.06] at 6 months and to 2.51 [1.88–3.04] after 12 months (p < 0.001). The outcomes improved most in subgroups with high eosinophils (≥300/μL) or FeNO (≥50 ppb) at baseline. AEs were reported by 45.3% (67/148), of which headache was most frequent. ConclusionsThis study indicates that dupilumab as add-on therapy for SA is associated with significant improvements in exacerbation-rate, mOCS-dependency, asthma control, pulmonary function, and quality of life. These results are in line with those of previous phase-III-trials.

HIV transmission among acutely infected participants of a Dutch cohort study 2015-2021 is not associated with large, clustered outbreaks.

Timely identification of acute or early HIV infection (AEHI) is important to help prevent onward transmission, and understanding the number of secondary infections resulting from individuals with AEHI is key to planning HIV prevention services and case finding. We performed a phylogenetic investigation of a dense sample of individuals with AEHI who took part in the Netherlands Cohort Study on Acute HIV infection (NOVA) in the Netherlands during 2015-2021. Transmission clusters were identified using phylogenetic analyses based on HIV pol sequences. The Tamura-Nei model was used to estimate genetic distance. A number of 1000 bootstraps was used to check the reliability of clustering using maximum likelihood. A cluster was defined as having a bootstrap value of at least 95% and a genetic distance of at most 1.5%. Sensitivity analyses using different values for the bootstrap and genetic distance were performed to study the reproducibility of the clustering. Of the 156 participants included in NOVA between July 2015 and April 2021, 134 individuals for whom baseline characteristics and genotypic resistance data at baseline were available could be included. We identified 10 clusters, but the majority of persons (111/134) were not part of a cluster, suggesting mainly independent transmission events. Mainly independent transmission events among a study population consisting predominantly of MSM in a low-incidence high-resource setting is likely the result of active AEHI case finding and direct start of treatment, and the roll-out over recent years of preventive measures such as preexposure prophylaxis.

Nationwide Pregnancy Outcomes After Kidney Transplantation and Prediction of Adverse Pregnancy Outcomes: A Dutch Cohort Study

Nationwide Pregnancy Outcomes After Kidney Transplantation and Prediction of Adverse Pregnancy Outcomes: A Dutch Cohort Study

Impact of influenza vaccination on GP-diagnosed COVID-19 and all-cause mortality: a Dutch cohort study

ObjectivesAs clinical presentation and complications of both viruses overlap, it was hypothesised that influenza vaccination was associated with lower general practitioner (GP)-diagnosed COVID-19 rates and lower all-cause mortality rates.Study designFrom...

How is atrial fibrillation detected in everyday healthcare? Results of aDutch cohort study.

Atrial fibrillation (AF) is acommon arrhythmia with serious potential consequences when left untreated. For timely treatment, early detection is imperative. We explored how new AF is detected in patients aged ≥ 65years in Dutch healthcare. The study cohort consisted of 9526 patients from 49Dutch general practices in the usual-care arm of the Detecting and Diagnosing Atrial Fibrillation study. We automatically extracted data from the electronic medical records and reviewed individual records of patients who developed AF. Patient selection started in 2015, and data collection ended in 2019. We included 258 patients with newly diagnosed AF. In 55.0% of the patients, the irregular heartbeat was first observed in general practice and in 16.3% in the cardiology department. Cardiologists diagnosed most cases (47.3%), followed by general practitioners (GPs; 33.7%). AF detection was triggered by symptoms in 64.7% of the patients and by previous stroke in 3.5%. Overall, patients aged 65-74years more often presented with symptoms than those aged ≥ 75years (73.5% vs 60.6%; p = 0.042). In 31.5% of the patients, AF was diagnosed incidentally ('silent AF'). Silent-AF patients were on average 2years older than symptomatic-AF patients. GPs less often diagnosed silent AF than symptomatic AF (21.0% vs 39.0%; p = 0.008), whereas physicians other than GPs or cardiologists more often diagnosed symptomatic AF than silent AF (34.6% vs 11.9%; p < 0.001). Most diagnoses were based on a12-lead electrocardiogram (93.8%). Diagnosing AF is amultidisciplinary process. The irregular heartbeat was most often detected by the GP, but cardiologists diagnosed most cases. One-third of all newly diagnosed AF was silent.

A nationwide Dutch cohort study shows relatively good pregnancy outcomes after kidney transplantation and finds risk factors for adverse outcomes

Although numbers of pregnancy after kidney transplantation (KT) are rising, high risks of adverse pregnancy outcomes (APO) remain. Though important for pre-conception counselling and pregnancy monitoring, analyses of pregnancy outcomes after KT per pre-pregnancy estimated glomerular filtration rate-chronic kidney disease (eGFR-CKD)-categories have not been performed on a large scale before. To do this, we conducted a Dutch nationwide cohort study of consecutive singleton pregnancies over 20 weeks of gestation after KT. Outcomes were analyzed per pre-pregnancy eGFR-CKD category and a composite APO (cAPO) was established including birth weight under 2500 gram, preterm birth under 37 weeks, third trimester severe hypertension (systolic blood pressure over 160 and/or diastolic blood pressure over 110 mmHg) and/or over 15% increase in serum creatinine during pregnancy. Risk factors for cAPO were analyzed in a multilevel model after multiple imputation of missing predictor values. In total, 288 pregnancies in 192 women were included. Total live birth was 93%, mean gestational age 35.6 weeks and mean birth weight 2383 gram. Independent risk factors for cAPO were pre-pregnancy eGFR, midterm percentage serum creatinine dip and midterm mean arterial pressure dip; odds ratio 0.98 (95% confidence interval 0.96-0.99), 0.95 (0.93-0.98) and 0.94 (0.90-0.98), respectively. The cAPO was a risk indicator for graft loss (hazard ratio 2.55, 1.09-5.96) but no significant risk factor on its own when considering pre-pregnancy eGFR (2.18, 0.92-5.13). This was the largest and most comprehensive study of pregnancy outcomes after KT, including pregnancies in women with poor kidney function, to facilitate individualized pre-pregnancy counselling based on pre-pregnancy graft function. Overall obstetric outcomes are good. The risk of adverse outcomes is mainly dependent on pre-pregnancy graft function and hemodynamic adaptation to pregnancy.