Pregnant Recipients Research Articles

Maternal Outcomes With Pregnancy In Heart Transplant Recipients

Maternal Outcomes With Pregnancy In Heart Transplant Recipients

Infertility, pregnancy and breastfeeding in kidney transplantation recipients: Key issues

Infertility, pregnancy and breastfeeding in kidney transplantation recipients: Key issues

COVID-19 vaccination in pregnancy: Need for global pharmaco-vigilance.

Coronavirus infectious disease has been around for more than 2 years as a pandemic, but now appears to have taken the form of an endemic. COVID-19 vaccination in pregnant women is presently being recommended and followed in most countries. However, robust scientific evidence on safety of the vaccine in the medium or long term, or regarding any adverse effects, is lacking. We searched the PubMed and gray literature for evidence on medium- or long-term effects of COVID-19 vaccination during pregnancy on the mother or her fetus/newborn and found limited data on this subject. Moreover, available evidence comes almost exclusively from the Western world. Any adverse effects of COVID-19 vaccination during or after pregnancy may take time to manifest. Therefore, there is a need to keep the cohort of vaccinated women and their children under scrutiny for any possible adverse effects. This is also needed to build confidence in the long term in the vaccines. A global pharmaco-vigilance or post-marketing surveillance network covering pregnant recipients of COVID-19 vaccines can identify and help to address any medium- or long-term adverse effects of the COVID-19 vaccines on pregnancy and the newborn.

PREGNANCIES IN KIDNEY TRANSPLANT RECIPIENTS, AN ANALYSIS OF 9 CASES

(Objective) Pregnancy in kidney transplant recipient continues to remain challenging due to a high rate of cesarean section along with preterm delivery, and concern for worsening renal function. This study examined the prognosis and perinatal management of post-transplant pregnancies. (Patients and methods) A total of nine post-transplant recipients at Niigata University Medical and Dental Hospital between 2007 and 2021 were retrospectively examined. (Results) All pregnancies were planned. Calcineurin inhibitors and steroids were continued, and antimetabolites were changed to azathioprine. The mean age at delivery was 33±3.8 years, and the mean time from renal transplantation to delivery was 6.5±3.5 years. Five patients (55.5%) had cesarean sections, while four (44.5%) patients had normal vaginal deliveries. The mean gestational age was 35±3.0 weeks, and the mean birth weight was 2,336±565.4 g. No congenital malformation was observed. The most common reason for early delivery was worsening renal function, seen in six (66.7%) patients. The mean serum creatinine level before pregnancy was 1.11±0.23 mg/dL and then worsened to 1.59±0.37 mg/dL during pregnancy. However, it recovered to 1.14±0.40 mg/dL after delivery. One patient had antibody-mediated rejection with donor specific antibody (DSA) prior to pregnancy, and her renal graft function worsened slightly after delivery. Another patient had a de novo DSA after delivery, which was not detected before pregnancy. (Conclusions) In our hospital, pregnancy in kidney transplant recipients were safe and renal graft function after delivery was relatively stable. Patients may require adjustment of calcineurin inhibitors during pregnancy, and the appearance of DSA after delivery should be noted.

Donor-derived cell free DNA (dd-cfDNA) in pregnant kidney transplant recipients

Distinguishing between allograft rejection, kidney disease progression, and preeclampsia in a non-invasive manner can be difficult in pregnant kidney transplant recipients. Donor-derived cell-free DNA (dd-cfDNA) is a biomarker that can be measured non-invasively to assess risk of allograft rejection. However, using dd-cfDNA to monitor allograft status in pregnant kidney transplant recipients requires distinguishing between fetal, donor, and recipient cfDNA fragments. In this study, we aimed to measure dd-cfDNA in a cohort of pregnant kidney transplant recipients using a combination of NIPT and transplant monitoring technology utilizing cfDNA.

Cesarean delivery under neuraxial anesthesia in a patient with a liver transplant

Introduction. Improved outcomes after liver transplantation contribute to a successful pregnancy and delivery in transplant recipients. Anesthesiology teams face challenges when providing perioperative care to patients who have a liver transplant and undergo cesarean delivery, which include: an increased rate of cesarean delivery, a high risk of infection, and a high risk of interaction between immunosuppressant and anesthetic drugs. Case outline. We report the case of a 28-year-old patient with a liver transplant (from a live donor) who underwent elective cesarean delivery under neuraxial anesthesia. Appropriate anesthetic management is critical to ensure optimal perioperative maternal and fetal outcomes. Cardiovascular stability after neuraxial anesthesia was maintained with adequate perioperative intravenous fluid management and early vasopressor(s) administration to preserve hepatic perfusion. Multimodal postoperative analgesia was administered; however, caution is required when prescribing drugs that have the potential for hepatic and renal side effects. Conclusion. Multidisciplinary team evaluation, planning, and preparation are vital for optimizing safe care and delivery of pregnant patients with transplanted organs.

First-Trimester Biochemical Serum Markers in Female Kidney Transplant Recipients-The Impact of Graft Function.

Data on serum biochemistry markers as a component of the first-trimester screening test in pregnant kidney graft recipients are limited. In the absence of a separate validated algorithm, biochemical testing is commonly used in the first-trimester screening in kidney transplant recipients. Therefore, the study aimed to analyze first-trimester serum biochemical markers and the first trimester combined screening results in pregnant kidney graft recipients. A retrospective study was carried out in pregnant women who underwent the first-trimester combined screening test performed per the Fetal Medicine Foundation (FMF) protocol in 2009−2020. The study group included 27 pregnancies in kidney graft transplant recipients, and the control group was 110 patients with normal kidney function, matched according to age, body mass index (BMI), and gestational age. The biochemical serum markers (free beta-human chorionic gonadotropin [beta-hCG] and pregnancy-associated plasma protein A [PAPP-A]) were evaluated using the FMF-approved Roche Elecsys® assay and exhibited as multiples of the median (MoM) values. Data on first-trimester screening test results, perinatal outcomes, and graft function (assessed using serum creatinine concentrations) were analyzed. The analysis of first-trimester screening parameters revealed no difference in nuchal translucency (NT) measurements and uterine artery flow. However, free beta-hCG MoM and PAPP-A values were higher in posttransplant pregnancies than in controls: 3.47 ± 2.08 vs. 1.38 ± 0.85 (p = 0.035) and 1.46 ± 0.81 vs. 0.98 ± 0.57 (p = 0.007), respectively. The false positive rate of trisomy 21 (T21) screening in graft recipients was 25.9% vs. 3% in the controls. The free β-hCG MoM values positively correlated with serum creatinine levels before (r = 0.653; p < 0.001), during (r = 0.619; p = 0.001), and after pregnancy (r = 0.697; p < 0.001). There was a statistically significant negative correlation for PAPP-A MoM values for postpartum serum creatinine concentration (r = −0.424, p = 0.035). Our results show significantly higher serum concentrations of free beta-hCG and PAPP-A in posttransplant pregnancies than in healthy controls, confirmed when exhibited as MoM values and their association with graft function was assessed by serum creatinine concentration. Taking those changes into account would reduce the high number of false positive test results in this group. The validated first-trimester screening algorithm that considers altered kidney function in pregnant kidney graft recipients remains to be developed.

Counselling, Research Gaps, and Ethical Considerations Surrounding Pregnancy in Solid Organ Transplant Recipients.

Survival after solid-organ transplantation has improved significantly, and many contemporary transplant recipients are of childbearing potential.There are limited data to guide decision-making surrounding pregnancy after transplantation, variations in clinical practice, and significant knowledge gaps, all of which raise significant ethical issues.Post-transplant pregnancy is associated with an increased risk of maternal and fetal complications. Shared decision-making is a central aspect of patient counselling but is complicated by significant knowledge gaps.Stakeholder interests can be in conflict; exploring these tensions can help patients to evaluate their options and inform their deliberations. We argue that uniform, evidence-based recommendations for pregnancy after solid organ transplantation are needed.Conducting research, including patient-engaged studies, in this area should be priority for the transplant community.

Outcomes of Pregnancies in Liver Transplant Recipients: Experience of a Single Center in Turkey.

Liver transplantation is the ultimate treatment for end-stage liver failure. As organ donation systems improve, more reproductive-age women are expected to undergo liver transplantation. Current studies indicate increased risk of some perinatal and maternal complications; however, the available data is still scarce. Therefore, we aimed to evaluate the maternal and fetal outcomes of pregnancies in liver transplant recipients. We retrospectively evaluated liver transplantations performed between 2011 and 2020 in a tertiary center. Perinatal, maternal, fetal outcomes and transplant status were assessed among pregnancies conceived after liver transplantation. Among 1137 patients, 82 (7.2%) were reproductive-age females. Ten pregnancies in nine patients were identified after liver transplantation. The mean age of patients was 29.3±6.1 at transplantation, and 32.5±5.4 at conception. The mean interval between conception and transplantation was 30.3±11.7 months. There were eight live births (80%), one miscarriage (10%) and one termination (10%). Three patients delivered<37th gestational week (37.5%). The median gestational age at birth was 38.5 (IQR: 5.21) weeks. The mean birth weight of infants was 2669.3±831 g. Two patients were diagnosed with preeclampsia (25%) and acute graft rejection episode was observed in one patient (10%) during pregnancy. Although the incidence of some perinatal complications, such as hypertensive disorders and preterm delivery, is increased in liver transplant recipients, pregnancy after liver transplantation appears to have favorable outcomes for the mother, fetus and transplant with close monitoring by a multidisciplinary team.

242.10: Pregnancy in Renal Transplant Recipients: Long Term Outcomes

242.10: Pregnancy in Renal Transplant Recipients: Long Term Outcomes

232.11: Longitudinal Surveillance of a Kidney Transplant Recipient During Pregnancy Using Quantification of Fetal and Donorderived Cell-Free DNA

Introduction: Following kidney transplantation, women of childbearing age often experience rapid restoration of fertility as the feedback mechanisms of the hypothalamic-pituitary-gonadal axis normalize. Although rates of rejection during pregnancy are comparable to the non-pregnant transplant population, subtle indications of allograft injury such as increases in serum creatinine or proteinuria can be masked by pregnancy related changes. Here, we describe a novel approach of allograft surveillance using quantification of fetal and donor-derived cell-free DNA (dd-cfDNA) throughout gestation and postpartum. Methods: The patient was monitored longitudinally with dd-cfDNA (AlloSure, CareDx) pre-pregnancy, during gestation and postpartum. For this analysis, specific SNPs were selected that are heterozygous in kidney donor and homozygous (same allele) in recipient and fetal cells. An average minor allele frequency (MAF) was calculated from these selected SNPs. This average represents half of the expected donor cfDNA% due to Hardy-Weinberg principle based on Mendelian genetics. Hence, calculated average MAF was multiplied by factor of 2 to calculate the kidney donor percentage. Results: A 39 year old female with a living related kidney transplant (transplanted September 2018) conceived in February 2021. The patient had a baseline creatinine of 1.4 mg/dl and median dd-cfDNA level of 0.44%. dd-cfDNA levels remained stable throughout pregnancy (median 0.42%, IQR 0.31-0.44%) and were consistent with pre-pregnancy baseline, in keeping with absence of allograft injury. The percentage of fetal cfDNA saw an exponential rise in the first trimester, plateaued in the second trimester and showed a rapid decay post-delivery. Allograft function remained stable throughout pregnancy until development of pre-eclampsia with an acute rise in serum creatine to 2.1 mg/dl, prompting delivery at 31 weeks (Figure 1). Conclusions: The estimated percent of fetal fraction of cfDNA increased with gestational age and rapidly declined post-delivery. Throughout pregnancy, dd-cfDNA levels remained consistent with pre-pregnancy baseline in the absence of graft dysfunction, rejection, or clinical events. This case study suggests that longitudinal monitoring of fetal and dd-cfDNA contributions during pregnancy in kidney transplant recipients is a feasible, novel approach for allograft surveillance in this high-risk patient population.

347.10: Worse Graft Outcome After Pregnancy in Female Transplant Recipients

347.10: Worse Graft Outcome After Pregnancy in Female Transplant Recipients

Vitrification and in-straw warming do not affect pregnancy rates of biopsied bovine embryos

In the cattle industry, in vivo or in vitro embryo production combined with genotyping and cryopreservation technologies allows the selection and conservation of embryos carrying genes for desirable traits. This study aimed to assess the efficiency of a vitrification method suitable for in-straw warming of biopsied in vivo derived (IVD) bovine embryos. Three experiments were carried out using two methodologies: the Cryotop®, the gold standard vitrification and 3-step warming methodology, or the VitTrans, a vitrification/in-straw 1-step warming method that enables direct embryo transfer to the uterus. In experiment 1, intact and biopsied in vitro produced (IVP) day 7 expanded blastocysts were vitrified using the Cryotop® and warmed in 1- or 3-steps. No differences in survival rates were recorded at 24 h after warming for intact or biopsied IVP blastocysts irrespective of the warming procedure. In experiment 2, the effect of the time from trophectoderm (TE) biopsy to vitrification/in-straw warming on post-warming survival rate was assessed. No significant differences in survival were observed when blastocysts were vitrified/in-straw warmed immediately after biopsy or after 3 h in culture when compared to intact blastocysts. In experiment 3, IVD embryos were vitrified 3 h after biopsy using the Cryotop® or the VitTrans method and pregnancy rates were assessed at day 60 after transfer. Fresh, biopsied embryos served as control. Similar pregnancy rates were observed when IVD biopsied embryos were transferred fresh or vitrified/warmed by the Cryotop® or VitTrans method. No significant effect of the embryo quality or developmental stage was detected on the percentage of pregnant recipients when IVD biopsied embryos were transferred fresh or after vitrification. While fresh female IVD embryos produced significantly higher pregnancy rates than male embryos, there were no differences in pregnancy rates when male or female vitrified/warmed embryos were transferred. About 81% from the biopsies analyzed successfully determined the embryo sex, confirming that DNA was there, and it was efficiently amplified. To conclude, our findings indicate that both vitrification methodologies produced similar post-warming outcomes for both intact and biopsied IVP embryos. Besides, vitrification/in-straw warming of biopsied IVD bovine embryos did not affect the viability to originate pregnancy, being a useful option for their direct transfer in field conditions.

Features of Pregnancy Management in Kidney Transplant Recipients.

Patients with end-stage renal disease are often infertile or have low pregnancy rates because of hypothalamic dysfunction. These endocrine and menstrual dysfunctions are restored after kidney transplant, which is one of the benefits of kidney transplant for women of childbearing age. Fertility improves rapidly within a few months after kidney transplant, and most women who were previously infertile are then able to conceive. Pregnancy after kidney transplant is challenging because of the risk of adverse complications such as maternal preeclampsia and hypertension, low birth weight, and preterm birth. In addition, there is a risk of side effects from immunosuppressive drugs and a risk of deterioration in graft function. Despite the risk of these complications, clinical analyses of data from our center showed that most pregnancies in kidney transplant recipients were successful and the pregnancy did not significantly affect the function or survival of the graft. Here, we have focused on what we know and what we do not know about "kidney health" and kidney disease in women and what we can and should learn in the future to improve kidney disease outcomes for all people.

Outcomes of Children with Fetal and Lactation Immunosuppression Exposure Born to Female Transplant Recipients.

Solid organ transplantation (SOT) is a lifesaving procedure for those with end-stage kidney, liver, heart, lung, and intestinal diseases, including females of childbearing age who wish to proceed with pregnancy following transplantation. While there is clear risk associated with use of mycophenolate during pregnancy, the risks associated with use of other immunosuppressant agents are less well understood, and the timing of use in pregnancy may be pertinent when considering the risk versus benefit for individual patients. In addition to overall fetal outcomes, including gestational age, birth weight, and mortality, this review summarizes published literature on additional complications that have been examined in association with maternal use during pregnancy and postpartum while breastfeeding. Compared with non-transplant pregnancies, pregnancies in transplant recipients are associated with lower birth weight and earlier gestational age. Effects associated with particular immunosuppressant agents in the infant include renal dysfunction from calcineurin inhibitors, myelosuppression from azathioprine, and decreased circulating immune cells with several agents. However, these effects are noted to primarily be transient, though the decrease in immune cells may predispose the infant to increased infectious complications in the first year of life. Utilizing relative infant dose estimations, nearly all commonly utilized immunosuppressants are likely safe during breastfeeding given the limited exposure to the infant.

Percentage Expression of Lewis B, Rh-e, N and ABO Antigens in descents of Bonny Kingdom, River, State, Nigeria.

Introduction: The presence of rare blood group antibodies in the blood of donors/recipients stimulate red cell alloimmunization and constitute a major cause of transfusion related reaction after a compatible ABO cross match, yet remain one of the less routinely assessed prior to blood donation and transfusion in Nigeria. This cross-sectional study was carried out among indigenes of Bonny kingdom in Rivers State Nigeria to access the percentage expression of Lewis B, Rh-e, N and ABO antigens in descent of Bonny Kingdom Rivers State Nigeria. Materials and Methods:- One hundred and twenty (120) apparently healthy subjects consisting of sixty (60) females and sixty (60) males aged between 18-50 years all indigenes of Bonny Kingdom were recruited by structured questionnaire for the study. 4mls of venipuncture blood was aseptically collected from each participant into vacutainer bottle containing 0.5 mL of 1.2 mg/mL dipottasium ethylenediaminetetraacetic acid anticoagulant and a 5% cell suspension was prepared and used to determine the various blood groups antigens using the standard tube Agglutination technique. Results: Results obtained shows a total of 94.1% (113) of the participants expressed Rh-e antigen, 45.8% (55) male and 48.3% (58) females. 7.5% (9) of the participants expressed the N antigen, 3.3% (4) male and 4.2% (5) females. 4.2% (5) of the study population expressed Lewis B antigen, 2.5% (3) males and 1.7% (2) female. The ABO system showed 68.5% (79) O blood group, 29.1% (35) male and 36.7% (44) female. 22(18.3%) typed for A blood group, 11.6% (14) male and 6.7% (8) female. For B blood group 14.2% (17) persons were typed, 7.5% (9) male and 6.7% (8) female while 1.6% (2) persons were typed as AB and they are all females. Conclusion: Rh-e phenotype occurred highest among the study participants. The proportion of the population without the expression of these antigens of the blood group tested has the potential to be alloimmunized during blood transfusion and develop antibodies, some of which can be responsible for transfusion reactions and haemolytic disease of the new born. This study has provided baseline data on the distribution of some blood group antigens in the Bonny Kingdom of Rivers State in Nigeria. Based on the finding in this study, it is recommended that Rh-e grouping be carried out on pregnant mothers, blood donors and recipients before transfusion; while Lewis B and N blood groups may be subjected to expansive population testing.

Acute kidney injury during pregnancy in kidney transplant recipients.

Pregnancy‐related acute kidney injury (AKI) is a public health problem and remains an important cause of maternal and fetal morbidity and mortality. The incidence of pregnancy‐related AKI has increased in developed countries due to increase in maternal age and higher detection rates. Pregnancy in women with kidney transplants is associated with higher adverse outcomes like preeclampsia, preterm births, and allograft dysfunction, but limited data exists on causes and outcomes of pregnancy‐related AKI in the kidney transplant population. Diagnosis of AKI during pregnancy remains challenging in kidney transplant recipients due to lack of diagnostic criteria. Management of pregnancy‐related AKI in the kidney transplant population requires a multidisciplinary team consisting of transplant nephrologists, high‐risk obstetricians, and neonatologists. In this review, we discuss pregnancy‐related AKI in women with kidney transplants, etiologies, pregnancy outcomes, and management strategies.

Safe for Mother, Baby, and Graft? Pregnancy After Liver Transplant: A Single-Center Experience

Although fertility is reduced in patients with liver cirrhosis, recovery of menstrual cycle is acquired after liver transplantation (LT) in most patients, and pregnancy in LT recipients is not unusual. The aim of this study was to evaluate the outcomes of pregnancies in LT recipients in our center. Data of 24 pregnancies in 14 LT recipients were collected and statistically analyzed. Demographic and clinical data were documented in each trimester of pregnancy and thereafter. The analysis was conducted in accordance with the 1975 Declaration of Helsinki and was approved by the ethics committee of the University Hospital Essen. Median patient age was 21.5 years (range, 2-32 years) at LT and 31 years (range, 19-41 years) at conception. Median time between LT and conception was 126 months (range, 38-332 months), and median gestation time of completed pregnancies was 38 weeks (range, 29-40 weeks). Seven pregnancies terminated in abortions (29%). Of all deliveries, 6 resulted in preterm births (35%) with median gestation time of 34.5 weeks (range, 29-37 weeks). Gestational diabetes mellitus was the most common maternal complication, occurring in 4 patients (17%). One patient suffered from preeclampsia (4%). Pregnancy-induced hypertension or acute cellular rejection was not reported in our cohort. None of the children had serious complications. Our data show favorable outcome for pregnancy in LT recipients for mother and offspring. However, these patients are still at risk, particularly regarding high rates of preterm delivery, and preconception counseling and multidisciplinary monitoring are crucial to manage possible complications.

Pregnancy in renal transplant recipient, management and follow up

Renal transplantation is the treatment of choice for end stage kidney disease. It gives better quality of life and patient survival than hemodialysis. Renal transplant ladies regain fertility within six months after renal transplantation. Pregnancy is allowed in the most of guidelines after one years of rejection free renal transplant period. Immunosuppressive drugs are crucially used even during pregnancy so, we try to minimize the risk of teratogenicity by using azathioprine, Calcineurin inhibitor and steroid. Hereby we report a case of pregnant transplant lady, received sirolimus and Mycophenolate Mofetil during unplanted pregnancy. We discuss her outcome in spite of the risk of teratogenicity. We represent an image of 4D ultrasound showing the fetus beside the transplanted kidney

Pregnant kidney transplant recipients with COVID-19; a report of two cases and literature review

If managing COVID-19 alone was a major challenge, one can expect an even greater challenge in certain scenarios, such as patients with kidney disease - including kidney transplant recipients (KT) – or pregnant women. When things could not get any worse, we just met the peculiar art of overcomplicating things: pregnant kidney and simultaneous kidney-pancreas (SKP) transplant recipients with COVID-19. Gleeson and colleagues (Imperial College, London) described the first similar case in April 2020. We describe two cases of pregnant KT and SKP transplant recipients with COVID-19, at different stages, and their evolution until delivery. Maternal and fetal outcomes are significantly affected by both KT and COVID-19, requiring a multidisciplinary approach with a well-trained team of obstetricians and nephrologists, as we will describe.