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Transplantation
adverse fetal affects. Atenolol should also be avoided because of its development of neurological or developmental delays. Breastfeeding in
association with fetal growth restriction.
24
renal transplant patients is controversial, as medications such as
steroids and cyclosporine are secreted in breast milk. There are few
For some women, hypertension in pregnancy coincides with pre- data to guide recommendations. Most physicians discourage
eclampsia, a condition associated with multiple maternal and fetal breastfeeding in this population, but ultimately women must determine
risks. Fifteen to twenty percent of maternal renal transplant patients their own risk threshold.
experience pre-eclampsia compared with 3–5% of the general
population.
24
Pre-eclampsia can be a particularly challenging Conclusion
diagnosis in allograft recipients, as some have pre-eclampsia’s Although there are multiple risks for potential parents to consider,
cardinal signs of hypertension and proteinuria at baseline. Infections pregnancy outcomes in allograft recipients are quite good when
are also more common in maternal renal transplant patients due to conception is approached in a proper timeframe with stable allograft
their immunosuppression regimens. Forty-two percent of renal function and immunosuppressant regimens. In order to improve our
allograft recipients experience urinary tract infections during ability to counsel women and their partners, we need prospective
pregnancy.
25
Other infections such as CMV and toxoplasmosis occur multicenter trials of this population. Current consensus recommendations
at higher rates and can cause fetal complications.
26
Proper pregnancy are based largely on retrospective data that have inherent bias.
surveillance by a multidisciplinary team including a nephrologist Specifically, more research in immunosuppressant selection, renal
and maternal–fetal medicine specialist can help to identify and treat allograft recipient offspring long-term outcomes, pregnancy impact on
such complications early. long-term graft function, and breastfeeding safety is needed. Despite the
limited data, nephrologists must take the time to counsel patients about
Pregnancy in renal allograft recipients also carries risk for the unborn fertility and pregnancy. Counseling should focus on informed decision-
children. Pre-term delivery and low birth-weights are more common making and risk–benefit ratios.
in transplant recipients, with pre-term delivery reported in up to 50%
of renal transplant patients.
21
The mean gestational age is 34 weeks in With appropriate counseling, women, their partners, and their care
infants born to renal allograft recipients.
27
Steroid use, infection, and providers can develop individualized conception plans that consider
acute allograft rejection also put women at increased risk for unique patient comorbidities, graft stability, and medications. ■
premature rupture of membranes, thus increasing the risk of preterm
deliveries.
27
There are limited prospective data to evaluate the long-
Jennifer E Flythe, MD, works at Oregon Health and Science University. She will begin her
term effects of early deliveries and low birth weights on the offspring
nephrology fellowship training in July 2010. Her research interests include pregnancy and
of renal transplant patients, but data from the NTPR suggest that transplantation, dialysis outcomes, cost-effectiveness analysis, and health policy.
developmental delays are observed in some of these children.
28
Suzanne Watnick, MD, is an Associate Professor in the Department of Medicine and
Finally, all immunosuppressants cross the placenta and thus carry
Director of the Nephrology Fellowship Training Program at the Oregon Health and Science
University. After completing a clinical renal fellowship at the University of California, San
inherent risk. Unfortunately, there are limited data about the long-term
Francisco and Yale University, and a Robert Wood Johnson Clinical Scholars’ fellowship at
effects of such in utero exposure. Children of renal transplant recipients
Yale, she moved to the Oregon Health and Science University in 2002.
should be followed longitudinally by their pediatricians for the
1. Davison JM, Bailey DJ, Pregnancy following renal patient, Seminars in Perinatology, 2007;31:372–7. outcomes of pregnancy after transplantation, Clin Transpl,
transplantation, J Obstet Gynaecol Res, 2003;29:227–33. 12. Watnick S, Rueda R, Reproduction and contraception after 2000:123–4.
2. Bagon JA, Vernaeve H, De Muylder X, et al., Pregnancy and kidney transplantation, Curr Opin Obstet Gynecol, 2008;20: 20. Fischer MJ, Chronic kidney disease and pregnancy:maternal
dialysis, Am J Kidney Dis, 1998;31:756–65. 308–12. and fetal outcomes, Adv Chronic Kidney Dis, 2007;14:132–45.
3. Palmer B, Sexual dysfunction in uremia, JASN, 1999;10: 13. McKay DB, Josephson MA, Pregnancy after kidney 21. McKay DM, Josephson MA, Pregnancy in recipients of solid
1381–8. transplantation, CJASN, 2008 3:S117–S125. organs: effects on mother and child, N Engl J Med,
4. Okundaye I, Abrinko P, Hou S, Registry of pregnancy in 14. McKay DM, Josephson MA, Reproduction and 2006;354:1281–93.
dialysis patients, Am J Kidney Dis, 1998;31:766–73. transplantation: report on the AST Consensus Conference 22. Alston PK, Kuller JA, McMahon MJ, Pregnancy in transplant
5. Ginsburg ES, Owen WF, Reproductive endocrinology and on Reproductive Issues and Transplantation, Am J Transplant, recipients, Obstet Gynecol Surv, 2001;56:289–95.
pregnancy in women on hemodialysis, Semin Dial, 2005;5:1592–9. 23. Umans JG, Medications during pregnancy:
1993;6:105–16. 15. Muirhead N, Sabharwal AR, Rieder MG, et al., The outcome antihypertensives and immunosuppressives, Adv Chronic
6. Anantharaman P, Schmidt RJ, Sexual function in chronic of pregnancy following renal transplantation: the Kidney Dis, 2007;14:191–8.
kidney disease, Adv Chronic Kidney Dis, 2007;14:119–25. experience of a single center, Transplantation, 24. Podymow T, August P, Hypertension in pregnancy, Adv
7. First MR, Combs CA, Weislttel P, et al., Lack of effect of 1992;54:429–32. Chronic Kidney Dis, 2007;14:178–90.
pregnancy on renal allograft survival or function, 16. Armenti VT, Moritz MJ, Cardonick EH, et al., 25. Oliveira LG, Sass N, Sato JL, et al., Pregnancy after renal
Transplantation, 1995;59:472–8. Immunosuppression in pregnancy, Drugs, 2002;62(16): transplantation: a five year single center experience, Clin
8. Ghahramani N, Behzadi A, Gholami S, et al., Postrenal 2361–75. Transplant, 2007;21:301–4.
transplant improvement of sexual function, Transplant Proc, 17. Harris RZ, Benet LZ, Schwartz JB, Gender effects in 26. Fuchs KM, Wu D, Ebcioglu Z, Pregnancy in renal transplant
1999;31:3144. pharmacokinetics and pharmacodynamics, Drugs, recipients, Semin Perinatol, 2007;31:339–47.
9. Hou S, Pregnancy in renal transplant recipients, Adv Ren 1995;50:222–39. 27. del Mar Colon M, Hibbard JU, Obstetric considerations in
Replace Ther, 2003;10:40–47. 18. Davison JM, Pregnancy in renal allograft recipients: the management of pregnancy in kidney transplant
10. Guazzelli CA, Torloni MR, Sanches TF, et al., Contraceptive problems, prognosis, and practicalities, Baillieres Clin Obstet recipients, Adv Chronic Kidney Dis, 2007;14:168–77.
counseling and use among 197 female kidney transplant Gynaecol, 1994;8:501–25. 28. Stanley CW, Gottlieb R, Zager R, et al., Developmental well-
recipients, Trasnplantation, 2008;86:669–72. 19. Armenti VT, Radomski JS, Moritz MJ, et al., Report from the being in offspring of women receiving cyclosporine post-
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80 US NEPHROLOGY
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