Tog Flashcards
What is the prevalence of renal transplantation in UK?
2-6 /10 000
30- 40 pregnancies/ year
What is the risk of acute rejection of renal transplantation in the first year?
10- 15 % and is associated with recipients under the age of 45 years
What pregnancy counseling for renal transplant recipient 1 year after transplantation with normal eGFr?
Can be reassured that there is no conclusive evidence that pregnancy will increase their risk of graft rejection , or cause a deterioration in their graft function.
What medication should be stopped before pregnancy in renal transplant recipient? When? Why?
- Mycophenolate mofetil - can be switched to azathioprine
- 3 month
- 1- wash out period prior to pregnancy
2- allows confirmation of graft stability
3- can be used for prepregnancy folate administration ( 400 mcg/ d)
Among medications that commonly prescribed in solid organ transplant recipients … which is considered to be safe in breastfeeding?
Azathioprine
Cyclosporine
Tacrolimus
Hydroxychloroquine
Among medications that commonly prescribed in solid organ transplant recipients … which is considered to be teratogenic in pregnancy?
Mycophenolate
ACE inhibitors
Angiotensin receptor antagonist
Warfarin
What is the prevalence of hypertension among pregnant women with renal transplantat?
More than 50 %
In women with renal transplants who don’t require antihypertensives outside of pregnancy, how many of them will commence treatment for hypertension during pregnancy?
16 % of them
In renal transplant recipients which facilitates the detection of an increase in proteinuria after 20 weeks of gestation in the context of diagnosing PET?
Quantification of proteinuria in early pregnancy
What medications commonly prescribed in renal transplant recipients that have diabetogenic effects? What is the occurrence rate?
1- Calcineurin inhibitors ( tacrolimus- cyclosporine)
2- prednisolone
🔴 estimated to occur in 4- 25% of renal transplant recipients.
Why is CS rates higher in pregnant women with renal transplants ?
Consequence of PET and / or FGR
Leading to iatrogenic preterm delivery.
Is renal transplantation a contraindication to vaginal delivery?
No
Neonatal outcomes in women with renal transplants are a composite product of what?
PET / FGR / prematurity
What is the effect of renal transplantation on pregnancy?
1-⬆️ PET 30-40%
2-⬆️ CS
3-⬆️ neonatal unit admissions
4-⬆️ ectopic pregnancy
5-GDM
6- preterm delivery
7- ⬇️ birth weight
8- ⬇️ gestational age
9- infection: UTI 30-40%
What is the most common cause of creatinine rising in pregnant women with renal transplants?
PET
What is the rate of acute rejection during pregnancy in women with renal transplants?
In UK 2%
Meta-analysis 4.2%
What to do if graft rejection is suspected in pregnancy?
Graft biopsy
Less difficult than native biopsy
More bleeding in pregnancy
Transplant rejection can be treated in pregnancy with…..
1-Corticosteroid
2-Optimization of tacrolimus/cyclosporine
3- biological agents
What cautions should be taken about Babies exposed to biologic drugs in utero ?
Avoid live vaccines ( tuberculosis rotavirus- live attenuated influenza- oral polio - typhoid - yellow fever- varicella- measles- mumps- rubella)
🔴 during the first 6 months of life
In addition to routine first trimester investigations what to check in pregnant women with renal transplant recipients ?
CBC
Renal function / liver function
Ca / phosphate
Albumin
24h urine protein: cr ratio
Mid stream urine sample for culture
What to expect about proteinuria in pregnancy in women with renal transplants?
To double.
Further doubling if the woman was taking an ACEi ot ARA prior to pregnancy when these teratogenic drugs are discontinued.
When to consider LMWH prophylaxis in pregnant women with renal transplants?
Urinary protein: creatinine ratio
> 300 mg / mmol. ( Normal less than 15)
Or
Urinary albumin: creatinine ratio
> 180 mg / mmol (normal less than 3)
What to consider about serological screening for chromosomal trisomy in pregnant women with renal transplants?
There is a possibility of false positive result /affected by renal excretion of Bhcg./
What is the frequency of monitoring renal function during pregnancy in pregnant women with renal transplants?
Monthly
What are the drugs that can lead to calcineurin inhibitors toxicity ( cyclosporine/ tacrolimus)?
Erythromycin
Clarithromycin
How much the increase of erythropoietin concentration in normal pregnancy?
2-4 folds
When to consider treatment with erythropoietin stimulating agents during pregnancy in women with renal transplants?
In iron replete anaemic women
When to discuss the mode of delivery in women with renal transplants?
30- 34 weeks of gestation
By : obstetric and transplant surgical team
What criteria should be suggestive of superimposed preeclampsia in pregnant women with renal transplants?
1- development of new proteinuria after 20 weeks.
2- an increase in BP to more than 160/110.
3- an increase in treatment to maintain BP < 160/110.
4- 100% increase in proteinuria
5- elevated transaminases / thrombocytopenia/ FGR.
6- ⬇️ placental growth factor
How to adjust mg sulfate dose in pregnant women with renal transplants with PET?
🔴Loading dose (4g) is given irrespective of renal function
🔴 maintenance infusion levels are halved in those with:
1- significant renal impairment
2- oliguria
🔴 mgso4 serum concentration can be checked at 4- 6 hours
Maintain concentration < 3.5 mmol/L
Intrapartum management of renal transplant recipients?
🔴 vaginal delivery is recommended
🔴 continuous CTG
🔴 oxytocin/ prostaglandin are safe
What is the risk of trauma to renal graft at CS? How to lower this risk?
1-2%
By midline skin incision
How to manage women with renal transplants who are taking prednisolone daily during labour?
They require IV hydrocortisone
( 50-100 mg / 6-8 hours) until they are able to tolerate oral medication.
What to monitor in renal transplant recipients Prior to discharge from the hospital after delivery?
BP should be stable
Less than 140/90
What contraceptions are preferred for women with renal transplants?
Progesterone only pills
Mirena
Progesterone implants
What are the recommendations about kidney donors in pregnancy?
Aspirin prophylaxis
Because the doubling of the risk of gestational hypertension
What is the prevalence of acute rejection in liver transplant recipients during pregnancy?
2-17%
Graft loss within 2 years of pregnancy: 10.5 %
The increase risk of PET in all solid organ transplant recipients warrants what?
Aspirin prophylaxis
What are the criteria for considering pregnancy after renal transplantation safe?
❤ wait 2 years after transplantation
1- no rejection in the previous year
2- graft function should be stable
( cr < 1.5 mg / dl)
3- no or minimal proteinuria
( < 500 mg / 24 h)
4- should be on stable dosage of immunosuppression
5- no infection that can affect the fetus ( cmv)
6- co morbidity conditions should be assessed and managed
7- normal BP or minimal hypertensive Rx.
What are the clinical signs of renal transplant acute rejection in pregnancy?
Fever/ oliguria/ renal enlargement
What is the frequency of antenatal visits in women with renal transplants?
Every 2 weeks;
* UTI / each visit
* BP - proteinuria/ each visit
* RF - serum levels of cyclosporine and tacrolimus/ 4 weeks
* screen for GDM / anemia/ graft rejection
What is the mechanism of action for calcineurin inhibitors?
Calcineurin inhibitorsare medicines which inhibit the action of calcineurin. Calcineurin is an enzyme that activates T-cells of the immune system.
