Pregnancy outcome in renal transplant recipients

Objective: To correlate pregnancy outcome with complications in pregnancy and transplantation-to-pregnancy interval in renal transplant recipients in Croatia. Method: Data on 23 pregnancies after prepregnancy stabilization of blood pressure and normalization of graft function were retrospectively analyzed. Result: The mean interval between transplantation and conception was 3.1 years. Primary renal disease was chronic glomerulonephritis in 7, chronic pyelonephritis in 7 and agenesis of right kidney and stenosis of left renal artery in 1 patient. There were 10 term and 5 preterm deliveries, 6 induced and 2 spontaneous abortions. The mean gestational age was 38.1 weeks and the mean newborn birthweight was 3015 g. The prematurity rate was 21.7%. Patients with arterial hypertension in pregnancy, elevated serum creatinine level and bacteriuria, as well as those with conception occurring less than 2 years after transplantation, had a higher rate of therapeutic and spontaneous abortions, preterm deliveries and low birth weight infants. Conclusion: The interval between transplantation and conception, as well as allograft function during pregnancy, seem to be of great importance for successful obstetric outcome in renal transplant patients.     

Renal transplantation and pregnancy. Apropos of a case

A cystic disease of the medulla is found in a young women at the 5th month of her first pregnancy and entails the death of the foetus in utero. The chronic renal insufficiency rapidly worsens and necessitates periodic hemodialysis. Renal transplantation is carried out from a brother with identical HLA. Two years later the graft is functioning well enough to permit another pregnancy. It proceeds without accompanying nephropathy. A caesarean operation carried out 36 weeks after amenorrhea gives birth to a girl who presents normal psychomotor development at two years of age. The authors consider the influence of pregnancy on the functioning of the kidney graft and the criteria permitting pregnancy after a renal transplant. They discuss the consequences of a renal transplant on the progress of the pregnancy and delivery. Finally, they study the effects of immunosuppressive treatment on the child in the short and long term.     

Risk factors for renal allograft survival in patients receiving cyclosporine immunosuppression.

BACKGROUND AND PURPOSE: Although cyclosporine (CsA) has been widely used in renal transplantation for more than 10 years, no large series of renal transplant patients has been studied in southern Taiwan. The purpose of this retrospective cohort study was to investigate the risk factors for graft survival in renal transplant recipients. METHODS: From August 1987 to January 1998, 101 primary cadaveric renal transplantations were performed. The minimum follow-up period was 1 year. CsA and prednisolone were initially used as immunosuppressive agents in all patients. Use of lower doses of CsA to reduce CsA trough level (50-99 ng/mL) in hepatitis B surface antigen (HBsAg)-positive recipients was attempted at 6 months after transplantation. RESULTS: Graft actuarial survival rates at 1, 5, and 10 years posttransplantation were 89%, 75%, and 57%, respectively. Acute rejection and increased recipient age were found to be significant risk factors (p < 0.05) affecting graft survival, with hazard ratios of 5.20 and 1.74, respectively, by multivariate analysis using a Cox proportional hazards model. Hepatitis B and/or hepatitis C infection had no influence on graft survival. CONCLUSIONS: In this series of cadaveric renal allograft patients, the risk factors affecting allograft survival were acute rejection and recipient age.     

Results with cyclosporine in renal transplantation in patients who have lost two previous allografts

We investigated the fate of the cadaver renal transplant done with cyclosporine and prednisone immunosuppression into a recipient who had suffered the loss of at least two prior allografts. Nineteen cadaver renal allografts were transplanted into 18 recipients. All 18 recipients had previously rejected at least two prior allografts. One of these rejected an allograft done at our institution with cyclosporine and prednisone and was included a second time in this series when a fourth allograft was received. Nine of 19 allografts were successfully transplanted. Average follow-up time was 39 months. Eight allografts were rejected. One graft was lost to technical complications. In one instance, the recipient died with a functioning graft. Duration of function of previous allografts was not found to be a critical determinant of third or fourth graft survival. Human leukocyte antigen matching was not a statistically significant determinant. Panel reactive antibody was higher in those who rejected the third or fourth allograft, but not with statistical significance. Recipients with the blood type A were less likely to enjoy successful third or fourth cadaver renal transplantation. We concluded that the "two time loser" renal allograft recipient should not be systematically denied subsequent transplantation.     

Efficacy of low-dose mycophenolate mofetil therapy for Taiwanese renal transplantation patients receiving primary cyclosporine immunosuppression.

BACKGROUND AND PURPOSE: Mycophenolate mofetil (MMF) in combination with cyclosporine or tacrolimus prevents acute rejection and chronic allograft failure in renal transplantation in Western countries. We began to add low-dose MMF to primary cyclosporine immunosuppressive therapy in renal transplantation at the Department of Surgery of National Taiwan University Hospital in 1998. This study compared low-dose MMF to conventional therapy in Taiwanese renal transplant recipients. METHODS: This retrospective cohort study determined the efficacy of low-dose MMF therapy (1 g/day in divided doses). A total of 275 cases with allograft kidney transplants were grouped according to whether they received transplants before or after the adoption of MMF therapy (Period I: 1987-1993; Period II: 1994-1997; Period III: 1998-September 2000). The prognostic significance of MMF therapy and graft and patient survival rate in each time period were assessed. RESULTS: The 18-month graft survival rate was 84.9% in Period I, 86.3% in Period II, and 91.9% in Period III. The 5-year graft survival rates in Periods I and II were 69.3% and 76.6%, respectively. Acute rejection was significantly detrimental to graft survival (p = 0.048), while MMF therapy was significantly advantageous to graft survival (p = 0.015); treatment when MMF was available was also significantly associated with better graft survival (p = 0.043). There was a negative correlation between acute rejection and graft survival (p = 0.035); MMF therapy produced a protective effect on graft survival independent of acute rejection (p = 0.010). CONCLUSION: Low-dose MMF therapy significantly improved graft survival after renal transplantation in Taiwanese kidney allograft recipients.     

Lymphocele after renal transplantation: a case report.

A case of lymphocele after an allograft renal transplant at the National Taiwan University Hospital is reported. A 32-year-old female patient received a kidney transplant from a cadaver donor on 23 November 1990 after a 10-year course of hemodialysis. Acute tubular necrosis of 31 days duration developed on the 6th postoperative day after a severe episode of acute rejection. On the 44th POD, sonographic examination showed an echo-free space between the graft and the urinary bladder. Emergent marsupialization through an intraperitoneal window of the lymphocele was performed on the 45th POD due to a sudden decrease in urine output. After releasing the compression of the lymphocele, the urine output returned to over 2,500 mL on the following day. The patient was discharged on the 63rd POD with normal renal function. Repeated sonographic examination showed no reaccumulation of lymphocele. The literature concerning lymphocele is reviewed.     

The many faces of multivisceral transplantation

The transplantation of multiple abdominal viscera, including liver-duodenum-pancreas, liver-stomach-duodenum-pancreas and liver-intestine, is being performed with increasing frequency and success. These procedures and other variations are derived from a seldom used multivisceral operation in which all of the foregoing organs are transplanted en bloc. It is described herein how the full multivisceral transplantation and its less extensive derivatives are based on the same principles of procurement, preservation and postoperative management. With all of these multiple organ permutations and with intestinal transplantation alone, management is complicated by inclusion in the grafts of a large lymphoreticular component that is capable of causing graft versus host disease (GVHD). Because of a systematic error in therapeutic philosophy, past efforts have been directed at altering or damaging the lymphoreticular cells by pretreatment of the donor or of the organs with drugs, irradiation or other means. From recent observations, the alternative approach is suggested of keeping these lymphoid depots intact, which then become the site of two way cell traffic after transplantation. With the use of powerful immunosuppression, such as that provided with FK 506, the donor lymphoreticular cells can circulate in the recipient without causing clinical GVHD, and the lymphoreticular cells in the graft become those of the recipient (local chimerism) without causing rejection. Even with avoidance of rejection and GVHD, metabolic interrelations between the grafted organs, and also between the graft organs and retained recipient viscera can affect the fate of the individual transplanted organs or retained recipient organs. The best delineated of these metabolic influences are mediated by the endogenous splanchnic hepatotrophic factors, of which insulin has been the most completely studied. An understanding of these various immunologic and nonimmunologic factors combined with more potent immunosuppression that is now available is sure to stimulate efforts at transplantation of abdominal organs and particularly of the hollow viscera that have resisted such clinical efforts.     

Prognostic significance of six-month estimated glomerular filtration rate in cadaveric renal transplantation.

BACKGROUND AND PURPOSE: We hypothesized a linear relative-risk model for graft survival of cadaveric renal transplantation, with a 6-month estimated glomerular filtration rate (GFR) employed as the linear parameter quantifying functioning renal mass and the detrimental effects of early chronic allograft nephropathy. METHODS: A retrospective study was conducted in a 15-year series of cadaveric renal transplantations (n = 227) with cyclosporin-based immunosuppression in a single transplant center. The Cockcroft-Gault formula was used for estimation of GFR, with a correction factor of 0.85 used for women. Stepwise Cox's regression analyses were applied to examine the prognostic significance of the 6-month estimated GFR. RESULTS: The Kaplan-Meier 5- and 10-year graft survival rates for this study were 80.67% and 59.43%, respectively. From univariate analysis, recipient gender, acute rejection and 6-month estimated GFR were significantly associated with graft survival (p < 0.05). Acute rejection became less significant (p = 0.0033) than 6-month estimated GFR (p = 0.0001) when 6-month estimated GFR was introduced in the stepwise regression procedures. CONCLUSION: We demonstrated that 6-month estimated GFR is a significant prognostic indicator in cadaveric renal transplantation and is an essential parameter in the regression modeling of long-term graft survival.     

Management of pregnancy in pancreas alone transplant recipient complicated with stage-4 chronic renal insufficiency and superimposed pre-eclampsia: Case report and literature review

Objective

With the prolonged life expectancy in solid organ transplant recipients, their quality of life and fertility desire become of particular concern. Pregnancy in pancreas-alone transplantation, although rare and complicated to manage, is not impossible anymore. We here report such a case with literature review to address this issue.

Clinical analysis of 206 cases of kidney transplantation.

From July 1981 to May 1991, 206 kidney transplantations were performed at the Chang Gung Memorial Hospital. There were 762 patients on our waiting list for transplantation at that time. Patient follow-up care was undertaken, alternately, by urologists and nephrologists. The average follow-up period was 4.0 +/- 2.8 years. Patient data were registered in the UCLA (University of California at Los Angeles) International Kidney Transplant Registry. Eighty patients received living-related transplants, 126 received cadaveric transplants. Twenty-four per cent of transplant recipients were carriers of HBsAg. Their survival rates were equal to those of non-carriers up to five years postoperatively, although they were prone to episodes of hepatitis. Nineteen kidneys were from HBsAg carriers with recipient survival rates, five years postoperatively, not significantly different from those who received kidneys from non-carriers. However, there was one case of seroconversion from HBsAg negative to HBsAg positive status. There were 19 deaths among the recipients, the major cause of death being infection (57.9%). Eight grafts were lost due to medical noncompliance. Malignant lymphomas were noted in three cases who are now alive and well. Three cases of hepatomas were noted, but unfortunately none of them survived. The transplant recipients were found to enjoy a better quality of life after undergoing psychiatric evaluation. The one-year patient survival rate was 97.4% and 96.2% for living-related and cadaveric transplants, respectively. The one-year graft survival rate was 96.0% and 88.5% for living-related and cadaveric transplants, respectively. Kidney transplantation is a well-accepted method of treatment for end-stage renal disease.     

Menstrual characteristics and pregnancy in women after renal transplantation.

OBJECTIVES: To evaluate menstrual characteristics and pregnancy complications after renal transplantation in women of childbearing age. METHODS: A 10-year retrospective case-control study was carried out in Esfahan Teaching Hospitals, Esfahan, Iran. The case group consisted of 50 female kidney transplant recipients of childbearing age and the control group of 100 women who were matched for age (+/-2 years) and parity with the study group. Menstrual characteristics and pregnancy data were collected by questionnaire and analyzed by chi(2) and t-tests. RESULTS: Menstrual characteristics were improved in the 50 women who had renal transplantation, 18 of them conceived, and 20 pregnancies were evaluated. The mean interval between transplantation and pregnancy was 35.5 months and the birth weight of 44% of the newborns was less than 2500 g. Pregnancy complications included hypertension (65%), premature labor (35%) and decreased GFR (15%) during pregnancy, with a mean gestational age at delivery of 34.8 weeks. The women who conceived during the first 2 years after renal transplantation had more maternal and neonatal complications. CONCLUSIONS: Pregnancy is possible and can be successful and safe after renal transplantation in recipients with normal kidney function. However, maternal and neonatal complications are common and occur more often in patients who conceive within 2 years of transplantation. Post-transplantation pregnancies are high risk and they should be managed in a tertiary center.     

Thrombotic Microangiopathy in a Pregnant Woman With Kidney Transplantation: A Case Report

BackgroundThe differential diagnosis of thrombotic microangiopathy (TMA) in pregnancy includes common conditions, such as preeclampsia. In women with kidney transplantation, additional causes of TMA must be considered.CaseA 22-year-old primigravid woman with a transplanted kidney presented with fetal growth restriction, hypertension, acute kidney injury, and hemolysis at 28 weeks gestation. While her clinical presentation was initially consistent with preeclampsia, hemolysis persisted beyond 1 week postpartum. Diagnoses of TMA associated with tacrolimus and antibody-mediated rejection were considered. An elevated tacrolimus level likely contributed to her TMA and a decrease in dosage improved her clinical picture and laboratory markers.ConclusionWe report the case of a pregnant kidney transplant recipient with TMA. A multidisciplinary approach is required to optimize the maternal health outcomes in this complex population.     

A review on pregnancy after intestinal transplantation

The largest experience of pregnancy after solid organ transplantation is recorded in renal and liver recipients. Intestinal/multivisceral transplantation has shown steady improvements in graft and patient survival over the past 20 years and is rapidly becoming more established: the first pregnancy after this procedure was described 10 years ago, and so far eight cases of pregnancies with 100% successful live births have been reported worldwide. Specifically to this procedure, there are 2 factors to be considered in case of pregnancy: absorptive function of transplanted bowel and higher need of immune-suppressants. Close monitoring of renal function and of the graft by endoscopies and biopsies can be considered during the pregnancy to prevent episodes of rejection or enteritis, preserving the fetus by temporary malnutrition. As more intestinal transplant patients are surviving and regaining reproductive function, it is important to report this option to female recipients and to their health-care professionals.     

Pancreaticoduodenal transplantation in humans

Whole cadaveric pancreata were transplanted to the pelvic extraperitoneal location in four patients with diabetes who previously had undergone successful cadaveric renal transplantation. One graft was lost within a few hours from venous thrombosis but with patient survival. The other three are providing normal endocrine function after two and a half, 11 and 12 months. The exocrine pancreatic secretions were drained into the recipient jejunum through enteric anastomoses. Because mucosal slough of the graft duodenum and jejunum in two patients caused a protein losing enteropathy and necessitated reoperations, we now do the pancreatic transplantation with only a blister of graft duodenum large enough for side-to-side enteroenterostomy. The spleen has been transplanted with the pancreas mainly for technical reasons, and this technique should have further trials in spite of the fact that delayed graft splenectomy became necessary in two recipients to treat graft induced hematologic complications.     

Pregnancy following kidney transplantation

Following kidney transplantation, 20 women gave birth to 24 infants after the 28th gestational week. All babies were singletons, alive, and free from malformations. The mean weight was 2,595 g (range 1,420-3,200 g) and the mean gestational age was 37.8 weeks (range 32-40 weeks). The cesarean section rate was 75%. On dividing the patients into low- and high-risk groups, the rate of pre-eclampsia, prematurity, and intra-uterine growth retardation was 2-3 times as high in the high-risk as in the low-risk group. No patients experienced graft rejection during the pregnancy but, within 3 months after delivery, two rejection episodes occurred. Later, a further 5 patients experienced graft rejection. All infants developed normally. We conclude that pregnancy following renal transplantation generally has a normal outcome and that the function of the transplanted kidney is unaffected by the pregnancy.     

Pheochromocytoma-related cardiomyopathy during the antepartum period in a preterm pregnant woman

We report a rare case of pheochromocytoma-related cardiomyopathy during the preterm period. The patient was a 33-year-old woman who was referred to our hospital at 34 weeks' gestation. Her pulse was 130 beats/min, blood pressure of 186/90 mmHg and oxygen saturation was 30-40%. Fetal bradycardia prompted an emergency cesarean section and, nine minutes after admission, a boy weighing 2774 g was delivered with Apgar scores of 2 at 1 min and 5 at 5 min. A preoperative echocardiogram showed reduced fractional shortening of 19%. At 8 h after the operation, cardiac arrest developed. An intra-aortic balloon pump and percutaneous cardiopulmonary support were inserted, and continuous hemodiafiltration was also commenced, after which her cardiac function and respiratory function gradually improved. Urinary catecholamine levels were elevated and abdominal computerized tomography confirmed the presence of a right suprarenal mass. Four months after delivery, she underwent a laparoscopic adrenalectomy and the mass was found to be a pheochromocytoma.     

Fertility and reproductive disorders in female solid organ transplant recipients

Solid organ transplantation can prolong the life of individuals with end-stage diseases that affect the kidney, liver, lung, heart, and pancreas. The improved survival of transplant recipients has led to increased attention on quality of life issues, including controlling fertility and having children. Perturbations of the hypothalamic-pituitary-ovarian axis in women with chronic renal failure or severe hepatic dysfunction result in anovulation and reduced fertility. Most often, fertility is restored with successful organ transplantation and good overall health. Although there are case reports of children born subsequent to assisted reproductive technologies (ART) in female transplant recipients, the approach to infertility in this population has not been described. Recognizing the unique medical, ethical, and psycho-social concerns involved in treating infertile female transplant recipients, reproductive endocrinologists must work with a multi-disciplinary team to ensure a successful pregnancy outcome without compromising graft function or maternal health. The primary goal of ART is a singleton pregnancy without complications, such as ovarian hyperstimulation syndrome, that pose greater risks in transplant recipients.     

Effect of sirolimus in combination with low-dose cyclosporine and steroids on acute renal allograft rejection.

BACKGROUND AND PURPOSE: Sirolimus is a novel immunosuppressive drug with much less nephrotoxicity than cyclosporine. The efficacy and toxicity of the combination of sirolimus and low-dose cyclosporine therapy were compared with data from records of a previous cyclosporine-based regimen used in patients with renal allograft transplantation. PATIENTS AND METHODS: A prospective study was conducted to assess the clinical effects of a sirolimus (6 mg loading dose over 48 hours plus 2 mg/day maintenance)/cyclosporine (8 mg/kg/day) combination regimen. Three male and 9 female renal transplant recipients were enrolled in the study. The primary endpoint was the incidence of acute rejection. The efficacy and adverse effects of the combined therapy were compared with those recorded in medical records of 24 renal transplant recipients who had received a cyclosporine-based regimen (10 mg/kg/day). RESULTS: The 12-month acute rejection rate of the study group was 16.67% (2/12), and that of the cyclosporine-based group 29.16% (7/24). One patient in the study group died of complications sustained during a radical operation for recurrent bladder carcinoma during the sixth post-transplant month. The 12-month graft and patient survival rates of the study group were both 91.8%. In the 12 months post-transplant, the mean serum creatinine levels of the study group were significantly lower than those of the historic group at months 1, 3, and 4. The average cyclosporine trough levels of the study group were significantly lower than those of the historic group at months 1, 2, and 12. The average daily doses of prednisolone in the study group were also lower than those of the historic group at months 2, 3, 4, and 12. CONCLUSIONS: The sirolimus/cyclosporine combination regimen reduced the incidence of acute renal allograft rejection, did not affect renal function, and reduced the dosage of cyclosporine and steroids compared with the cyclosporine regimen.     

Unaware of a giant serous cyst adenoma: a case report

A case of 36-year-old nonmarried virgin woman presenting a giant ovarian serous cyst adenoma weighing 9.5 kg is reported here. Ovarian neoplasms may be divided by origin cell type into three main groups: epithelial, stromal and germ cell. Taken as a group, the epithelial tumors are by far the most common type. The single most common benign ovarian neoplasm is the benign cystic teratoma; however, according to some studies it is serous cyst adenoma. A 36-year-old nonmarried virgin woman was referred to our clinic from a local medical center. When she was seen first at our outpatient clinic, she looked like a 9-month pregnant woman. Her medical history was normal. She had no serious illness or operation before. On abdominal ultrasound, a giant cyst was found which encompassed the whole abdomen. At laparotomy, a giant, totally cystic, vascularized and smooth mass attached to the right ovary was encountered, lying between the symphysis and the xiphoid. Ooferectomy was performed. On the postoperative second day, she was discharged without any problem. Her pathology report disclosed a 35×20×16 cm³ serous cyst adenoma weighing 9.5 kg. This is the largest ovarian cyst that ever reported from our hospital and one of the largest among the reported cases in the literature.     

Cytomegalovirus-associated immune thrombocytopenic purpura after liver transplantation.

Immune thrombocytopenic purpura (ITP) is a rare complication after liver transplantation. Infection with cytomegalovirus (CMV) is a frequent complication of organ transplantation and may induce autoimmune diseases, such as ITP. We report a case of ITP after primary CMV infection in a 3-year-old boy recipient of living-related orthotopic liver transplantation (OLT). The ITP developed 2 years after OLT in this patient who had received tacrolimus as an immunosuppressive agent, with nadir platelet counts of 5000/mm(3) in 2 weeks. The patient was treated with two courses of intravenous gamma globulin (1 g/kg/day for 2 days) and subsequent oral prednisolone (1.3 mg/kg/day for 2 weeks). He recovered from thrombocytopenia 4 weeks later. An inadequate immunosuppression, as evident by the low serum tacrolimus level (5.8 ng/mL before the episode of ITP) in this patient, may allow the development of ITP after CMV infection.