Renal Transplant

Question 1

How do you counsel a patient with a renal transplant regarding maternal risk in pregnancy?

Answer 1

• The most common complication is hypertension
• The risk for irreversible loss of renal allograft function is minimal when the creatinine level is less than 1.5 mg/dL at the time of conception.
• When the pre-conception creatinine level is greater than 1.5 mg/dL, however, the risk for irreversible loss of renal allograft function is increased during and after pregnancy.

Question 2

How does a renal transplant in a pregnant patient impact outcomes in pregnancy?

Answer 2

• Approximately 13% of pregnancies among renal transplant recipients have a miscarriage
• For pregnancies that continue beyond the first trimester, more than 90% result in a successful maternal and fetal outcome.
• There is a substantial risk for:
• low birth weight (25% to 50%)
• preterm delivery (30% to 50%) preeclampsia is the primary indication for preterm delivery

-The rate of ectopic pregnancy may be slightly increased in women with a renal allograft, but it remains below 1%

Question 3

Following renal transplant, what factors predict higher likelihood of poor pregnancy outcome?

Answer 3

-When the pre-conception creatinine level is greater than 1.5 mg/dL, however, the risk for irreversible loss of renal allograft function is increased during and after pregnancy.

Question 4

How does pregnancy impact renal function in the transplanted organ?

Answer 4

graft function is adequate and stable with minimal to no proteinuria

Question 5

Does pregnancy impact graft rejection?

Answer 5

Pregnancy within the first 6 to 12 months after transplantation is not recommended for the following important reasons: the risk for acute allograft rejection is relatively high

Question 6

What baseline evaluation should be performed in pregnant patients with a renal transplant?

Answer 6

• CBC/CMP/24 hour urine protein and creatinine clearance

- maternal blood titers of IgM and IgG antibodies against both CMV and Toxoplasma in each trimester.

Question 7

How do you monitor a patient with renal transplant in pregnancy?

Answer 7

• transplant nephrologist collaboration

- allograft function should be serially assessed and biopsy performed if there is a concern for acute rejection

Question 8

How do you counsel transplant patients regarding immunosuppressants in pregnancy?

Answer 8

Cyclosporine (or tacrolimus, although data for it are more limited) and steroids, with or without azathioprine, form the basis of immunosuppression during pregnancy.

Question 9

Which immunosuppressants are safe to use in pregnancy?

Answer 9

Cyclosporine

Tacrolimus

Question 10

Is mode of delivery altered for transplant patients?

Answer 10

No except for in the event of active HSV which is at an increased risk of occurrence due to immunosuppressant drugs

Question 11

How does acute renal allograft rejection present?

Answer 11

fever, oliguria, graft tenderness, or deterioration in renal function.
occurs in 6% in pregnancy which is similar to nonpregnant state