Dialysis, transplantation, and pregnancy

Women on regular dialysis are usually infertile, but contraception should not be neglected. Pregnancy is invariably complicated and poses excessive risks, with an uncertain and low chance of success. Even when therapeutic abortion is excluded, the live birth outcome at best is 19%. Renal transplantation usually reverses abnormal reproductive function and comprehensive pre-pregnancy counseling is essential, with discussion of all implications, including the harsh realities of long-term maternal survival. In this survey of 2,309 pregnancies in 1,594 women, therapeutic abortion was undertaken in 27% of conceptions and the spontaneous abortion rate was 13%. Of the conceptions that continued beyond the first trimester, 92% ended successfully. In most, renal function was augmented in pregnancy, with transient deterioration in late pregnancy (with or without proteinuria). Permanent renal impairment occurred in 15% of pregnancies. There was a 30% chance of developing hypertension, preeclampsia or both. Preterm delivery occurred in 50%, and intrauterine growth retardation in 25% of pregnancies. Despite its pelvic location, the transplanted kidney rarely produced dystocia and was not injured during vaginal delivery. Cesarean section should be reserved for obstetric reasons only. Neonatal complications include respiratory distress syndrome, leukopenia, thrombocytopenia, adrenocortical insufficiency, and infection. No predominant or frequent developmental abnormalities have been described and data on infancy and childhood are encouraging. For the future more work is needed to improve pre-pregnancy assessment criteria, to understand the mechanisms of gestational renal dysfunction and proteinuria, to assess the side effects and implications of immunosuppression in pregnancy, and to elucidate the remote effects of pregnancy on both renal prognosis and the offspring.     

Management of pregnancy after augmentation cystoplasty

Reconstructions of the bladder using bowel are performed with increasing frequency; however, published experience with pregnancy after augmentation cystoplasty is extremely limited. Complications produced by pregnancy in women who have undergone such complex procedures may endanger the patient or her fetus, and can disrupt the reconstruction or impair renal function. A review was made of the available literature, in order to improve the counselling to patients who have undergone augmentation cystoplasty and desire to bear children, and to develop an approach to the management of their pregnancy. The incidence of complications during pregnancy after an augmentation cystoplasty is low, and the majority of these women can have an uneventful pregnancy and vaginal delivery. Close observation of renal function and prophylaxis against urinary tract infection during pregnancy are recommended. Elective cesarean section is advised for women who have had a reconstruction of the bladder neck or urethra or who have received an artificial urinary sphincter. Urologists and gynecologists must continue to report the outcome of pregnancy in their patients who have undergone major urinary reconstructions, if we are to develop meaningful data about the incidence of complications.The views expressed in this article are those of the author and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Government     

Extracorporeal shock wave lithotripsy of renal calculi during early pregnancy.

OBJECTIVE: To evaluate the safety of renal stone treatment by extracorporeal shock wave lithotripsy (ESWL) during pregnancy. PATIENTS AND METHODS: Data from 824 women of reproductive age who were treated by ESWL were analysed and the patients surveyed using a questionnaire about pregnancies, to which 636 (76%) responded. Of these patients, six had inadvertently undergone ESWL for renal stones during the first month of pregnancy. The stones were detected and located during ESWL using ultrasonography. RESULTS: The six patients gave birth to six children who had no detectable malformations or chromosomal anomalies. CONCLUSION: Although these results suggest that there were no adverse effects of ESWL during early pregnancy, a larger series should be assessed to confirm the safety and long-term effects of ultrasound-guided ESWL in the treatment of renal calculi during pregnancy. We do not advocate lithotripsy as a treatment for renal calculi in pregnancy, but inadvertent lithotripsy in a pregnant woman is not a cause for concern.     

Augmentation cystoplasty and ileal conduits in pregnancy

The authors report a case of successful pregnancy following augmentation cystoplasty in a patient who had refractory interstitial cystitis. A review of the literature discusses the incidence of pyelonephritis, premature delivery, impaired urinary drainage, renal insufficiency and the need for Cesarean section in pregnant patients who have had ileal conduits and augmentation cystoplasties. Careful urologic monitoring of such patients after urinary diversion or augmentation cystoplasty should result in a successful pregnancy.Editorial comment: This is a case report and literature review that tabulates pregnancy-related problems in patients who have undergone ileal conduits or augmentation cystoplasty. Pregnancy should not be discouraged in these patients. Most of these patients do well and deliver vaginally at term. Cesarean section should be reserved for obstetric indications only, unless there has been previous bladder-neck reconstruction or artificial genitourinary sphincter placement. Although pyelonephritis is relatively uncommon (approximately 15%), preterm delivery rates of 23%–38% are concerning, and indicate that these patients need to be carefully monitored for this complication. Ileal conduit patients were more likely to have impaired urinary drainage; typically, this was caused by compression of the left ureter against the sacrum by the gravid uterus. Worsening renal function was rarely seen. Pregnant patients who have undergone these two procedures should be monitored for infection, urinary obstruction and preterm labor.     

Urinary infection in kidney transplantation.

Urinary tract infection is the most frequent complication following renal transplantation and is important in the etiology of post-transplantation sepsis. The 87 renal homografts done in 1974 at The New York Hospital-Cornell Medical Center were reviewed retrospectively, with at least one year follow-up, in all cases, with particular attention to factors relating urinary tract infection to ultimate success or failure of the renal graft. The over-all incidence of urinary tract infection was 61%. Early infection was associated with a particularly poor prognosis for graft survival. Most patients with urinary infections after successful transplantation experience a combination of both early and late infections. Anatomic factors constitute a remediable cause of urinary infections after transplantation and should be searched for in cases of multiple, recurrent infections, de novo hypertension, or deterioration of previously stable graft function. There were significant differences in the bacteriologic spectrum of urinary tract infections associated with successful transplants as opposed to unsuccessful transplants.     

Successful pregnancy in renal transplant recipient with previous known polyomavirus nephropathy

Pregnancy after renal transplantation has become increasingly common. Studies in non-immunocompromised patients have shown that pregnant women have increased susceptibility to infection or reactivation of latent virus such as BK virus. To what extent a renal transplant recipient is at risk for reactivation of polyoma virus during pregnancy remains unknown. We hereby report successful pregnancy outcome in a renal transplant recipient with a known history of BK virus nephropathy treated with cidofovir i.v. To our knowledge, this is the first published experience with a successful pregnancy in renal transplant recipients with known history of polyomavirus-associated nephropathy.     

Considerations in the medical management of pregnancy in transplant recipients

Pregnancy, although rare in the patient with end-stage renal disease, is not uncommon in the transplant recipient. Physicians taking care of transplant recipients must be able to inform patients about the potential risks of pregnancy in this setting. The patient and her partner must know that the risks associated with pregnancy increase with worsening kidney function and hypertension. Current consensus opinion is that pregnancy can be relatively safely undertaken by 1 year after transplant if the patient has had no rejections during the year, allograft function is adequate, there are no infections that could affect the fetus, the patient is not taking teratogenic medications, and immunosuppressive medication dosing is stable. Consideration must be given to immunosuppression during pregnancy both with respect to the specific agents as well as the level of dosing. None of the medications are FDA category A; all are B or higher. Part of planning for pregnancy should include an evaluation of immunosuppression medication and a plan to modify the regimen prior to conception if its use may be risky for the developing fetus. Rejection can occur during a kidney transplant, so maintaining adequate immunosuppression is important. Other issues that need to be managed when caring for a pregnant transplant patient include: potential for infection (urinary tract infections are very common), hypertension, and anemia. The type of delivery, posttransplant contraception, and breast-feeding also need to be addressed.     

Postpartum renal failure in a patient with membranoproliferative glomerulonephritis type II

The previously reported detrimental effects of pregnancy on the course of membranoproliferative glomerulonephritis type II (MPGN type II) are limited and are usually considered to be mild. Based on these reports, a 19-year-old female with the diagnosis of MPGN type II who had stable renal function (creatinine 0.9 mg/dl) and a mild nephrotic syndrome with hypertension for 5 years of close follow-up was advised to complete her pregnancy. After a full-term pregnancy, complicated only by moderate nephrotic syndrome, a healthy female infant was born. Two weeks after delivery, the patient presented with acute renal failure and malignant hypertension, without evidence of hemolysis of hepatic failure. Immunologic parameters, including, C3, C4, antinuclear antibodies, circulating immune complexes as well as antibodies to glomerular basement membrane antigen and tubular basement membrane antigen were negative. Peritoneal dialysis was initiated and a renal biopsy was performed which showed MPGN type II with 50% crescents. Despite pulse therapy with methylprednisolone, renal function did not improve, resulting in the need for chronic dialysis. Although no specific nephritogenic mechanism was shown, the course of this patient should be considered when counseling female patients with MPGN type II, regarding the possibility of pregnancy exacerbating their disease, or resulting in rapidly progressive renal failure.     

Limb salvage surgery in end stage renal disease: is it worthwhile?

The role of limb salvage surgery in patients with end stage renal disease (ESRD) is controversial. In view of this debate, we reviewed our experience with 54 primary and 15 secondary revascularizations for limb salvage in patients with ESRD over the past decade. Thirty-seven patients required dialysis and 10 had functioning renal transplants. Severe limb threatening ischemia was the indication for all revascularizations. The 2-year cumulative secondary graft patency rate was 56.2% with an associated limb salvage rate of 71.4%. There was no significant difference in graft patency or limb salvage rates between patients requiring dialysis and those with functioning renal allografts (p = 0.5). The 30-day operative mortality for the 99 surgical procedures (69 arterial bypasses and 30 additional operations) was 13% and the 2-year patient survival was 45.6%. Six of the 15 amputations were performed despite a patent graft on limbs which had extensive infection and gangrene. We conclude that limb salvage surgery should only be undertaken with recognition of these risks in patients with ESRD or functioning renal transplants. Surgery should be performed before gangrene and infection become extensive. Patients with unrelenting infection or mid-forefoot gangrene should be considered for primary amputation.     

Risk of Severe Coronavirus Disease 2019 Infection in Kidney Transplant Recipients

BackgroundDespite all efforts, the incidence of severe coronavirus disease 2019 (COVID-19) infection has been high in renal transplant recipients, as in other groups (eg, older adults, patients with comorbidities or immunosuppression). The detection of any possible predictor of gravity could improve the early approach in these patients.Patients and methodsWe registered data from renal transplant recipients with severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) infection in our area for a year (March 2020 to March 2021). We collected demographics, comorbidity, body mass index, lymphocyte count, and vitamin D levels before the diagnosis. We performed statistical analysis using SPSS Statistics version 20 (IBM Corp, Armonk, NY, United States).ResultsOf 63 patients, 57.1% required hospital admission and 14.3% required intensive care. The incidence of acute renal failure was 28.6%; 34.9% developed hyperinflammatory syndrome; 67% had lymphopenia, which was severe in 13.1%; and 11 patients died. There was significant correlation between lymphocyte count before and during the infection. For hospitalization, we found differences in age, pulmonary disease, and renal function. Related factors for admission to an intensive care unit were obesity, severe lymphopenia, altered renal function, and low level of vitamin D. Predictors for mortality were age, renal function, and minimum lymphocyte count.ConclusionIn kidney transplant recipients with COVID-19 infection, renal function determines hospitalization, and body mass index determines admission to an intensive care unit. Previous vitamin D levels are also significantly lower in patients requiring intensive care. The analysis of lymphocyte count previous to infection is correlated with the minimum level during the disease, which is a predictor of mortality, and could be a prognosis factor.     

Relationship between tonsils and IgA nephropathy as well as indications of tonsillectomy

Although there are many papers about IgA nephropathy (IgAN) and tonsils, respectively, reviews about the relationship between tonsils, tonsillitis, tonsillectomy, and IgAN are limited. In this review, we introduced the structure, development, and function of tonsils, difference of tonsils with and without IgAN, consistency of both tonsillar IgA and glomerular IgA, the effect of tonsil stimulation, tonsil infection, and tonsillectomy on IgAN showed some evidences in which tonsils were closely related to IgAN and polymeric IgA1 deposited in glomerular mesangium were at least in part of tonsillar origin. Tonsillectomy can improve the urinary findings, keep stable renal function, improve mesangial proliferation and IgA deposit, have a favorable effect on long-tern renal survival in some IgAN patients, and do not cause significant immune deficiency and do not increase incidence of the upper respiratory tract infections, and can be used as a potentially effective treatment. The indications of tonsillectomy in patients with IgAN include mainly the deterioration of urinary findings after tonsillar infection, mild or moderate renal damage. However, tonsillectomy may not be enough and may not change the prognosis in IgAN patients with marked renal damage.     

Chronic kidney disease in pregnancy

Parturients with renal insufficiency or failure present a significant challenge for the anesthesiologist. Impaired renal function compromises fertility and increases both maternal and fetal morbidity and mortality. Close communication amongst medical specialists, including nephrologists, obstetricians, neonatologists and anesthesiologists is required to ensure the safety of mother and child. Pre-existing diseases should be optimized and close surveillance of maternal and fetal condition is required. Kidney function may deteriorate during pregnancy, necessitating early intervention. The goal is to maintain hemodynamic and physiologic stability while the demands of the pregnancy change. Drugs that may adversely affect the fetus, are nephrotoxic or are dependent on renal elimination should be avoided.     

Delayed presentation of posterior urethral valves: a not so benign condition

PURPOSE: Posterior urethral valves are usually detected during infancy by prenatal sonography. Rarely they may be diagnosed during later childhood, adolescence or even adulthood. Less is known about presentation and outcome in these older patients. We reviewed our experience at 4 institutions with the late presentation of posterior urethral valves. MATERIALS AND METHODS: A 13-year retrospective review revealed the late presentation of posterior urethral valves in 47 patients 5 to 35 years old (mean age 8). Data collected included presenting symptomatology, radiographic findings and renal function. Statistical analysis determined the relationships among presenting symptoms, patient age at diagnosis and renal function. RESULTS: The most common presenting symptoms were diurnal enuresis in 60% of the cases, urinary tract infection in 40% and voiding pain in 13%. Other presenting symptoms in less than 10% of the cases included poor stream, gross hematuria and proteinuria. At diagnosis hydronephrosis and vesicoureteral reflux were present in 40 and 33% of the patients, respectively, while serum creatinine was elevated in 35% and end stage renal disease had developed in 10%. The severity of presenting signs and symptoms was significantly associated with renal impairment, while patient age at diagnosis was not. CONCLUSIONS: Posterior urethral valves is not merely a disease of infancy. Voiding cystourethrography should be considered in boys older than 5 years who have voiding complaints, especially in association with diurnal enuresis or urinary tract infection. Patients who present late with posterior urethral valves are at risk for progression to end stage renal disease.     

肝移植术后急性肾功能衰竭的预防和治疗

目的总结肝移植术后急性肾功能衰竭的预防和治疗经验。方法回顾性分析63例原位肝移植术后早期发生急性肾功能衰竭患者的临床资料,探讨其发病的危险因素及治疗方法。结果63例患者中,12例术前已存在不同程度的肾功能损害,28例有严重的腹水及进行性高胆红素血症。术后发生肺部感染28例,多器官功能衰竭26例,腹腔内积液、积脓9例。所有患者肝移植术后均采用环孢素A、霉酚酸酯或他克莫司预防排斥反应。23例患者应用多巴胺(2-5μg·kg-1·min-1)等血管活性药物改善肾脏灌注,并酌情配合利尿药物的使用,同时给予白蛋白、新鲜血浆输注、营养支持及抗感染治疗。12例病情较重者给予持续性肾脏替代治疗(CRRT),平均治疗时间50 h。术后1个月时,有26例患者死亡,死亡率为41．27％。结论肝移植术前应重视对肾功能的评估并及时处理,术后尽量避免感染。免疫抑制剂的个体化应用,改善肾脏灌注,可提高肝移植术后急性肾功能衰竭治疗的成功率。     

Successful Renal Transplantation During Pregnancy

Little is known about the implications of performing a renal transplant on a patient who is already pregnant. This case study reports a successful outcome of pregnancy, diagnosed coincidentally following renal transplantation at 13 weeks gestation. The recipient was a 23-year-old woman with chronic kidney disease who received a live-related renal transplant from her father. Pregnancy was discovered at routine ultrasound scanning of the renal allograft at 5 days posttransplant and estimated at 13 weeks gestation. She received ciclosporin monotherapy as immunosuppression throughout the pregnancy, and was given valacyclovir as prophylaxis against cytomegalovirus (CMV) infection. Renal function remained stable throughout the pregnancy, which progressed normally, resulting in the vaginal delivery of a healthy, liveborn male infant at 37 weeks gestation. This case study demonstrates that transplantation during pregnancy can have a successful outcome.     

The natural history of prenatal hydronephrosis with normal amounts of amniotic fluid

Thirteen cases of fetal hydronephrosis associated initially with normal volumes of amniotic fluid were diagnosed by maternal sonography. No invasive procedures were done in utero. Postnatal evaluation demonstrated 8 neonates with urinary tract obstruction and 5 normal neonates. Long-term followup of these 13 patients revealed that 12 are healthy and have normal renal function. The exception is a child whose amniotic fluid decreased during pregnancy. Our data suggest that fetuses with normal volumes of amniotic fluid do well. Treatment should be limited to frequent prenatal sonography and subsequent early postnatal evaluation. Caution should be exercised with the diagnosis of hydronephrosis, since 5 of our patients had false positive findings. In the rare instances when oligohydramnios develops during pregnancy fetal intervention may be warranted.     

Outcome of pregnancy in renal allograft recipients: SIUT experience

The course of pregnancy and its outcome was studied in renal allograft recipients. Between November 1985 and November 2005, a total of 1481 renal transplants were carried out at the Sindh Institute of Urology and Transplantation (SIUT); among them were 348 females, with 73 potential females for pregnancy. All patients received cyclosporine and prednisolone, with 82% also receiving azathioprine and 4 patients mycophenolate mofetil as a third immunosuppressant drug. We evaluated incidence of hypertension, diabetes, pre-eclampsia, urinary tract infection (UTI), rejection during pregnancy and during 3 months' postdelivery as well as outcomes of pregnancy. Among 73 potential candidates, 31 had 47 pregnancies, after an average of 31 months (8-86 months). Of 31 subjects, 21 subjects were hypertensive on one or two drugs prior to conception. A rise in blood pressure during pregnancy was noticed in 7 patients. Albuminuria from trace to 3+ appeared in 13 patients and glycosuria in one other. Blood sugar levels remained within normal range in all subjects. UTIs occurred during pregnancy in 7 patients. Among 47 pregnancies, 9 had abortions (7 spontaneous, 2 therapeutic) and 6 had preterm deliveries. The others were full-term deliveries: 12 via a lower segment caesarean section and 20 were normal vaginal deliveries. Average birth weight was 4.8 lbs. At an average follow-up of 38 months the serum creatinine values ranged from 0.94 to 2.3 mg %. One patient developed acute irreversible graft dysfunction soon after delivery. Our study demonstrated that pregnancy did not reduce renal graft survival, but newborns are at greater risk of premature birth and low birth weight.     

Pregnancy after organ transplantation: a report from the UK Transplant pregnancy registry

BACKGROUND: Maternal and fetal complications in pregnancies after renal transplantation have been highlighted in several reports, but information on their main predisposing factors is limited. The U.K. Transplant Pregnancy Registry was established in 1997 to obtain detailed information on pregnancies in female organ transplant recipients across the U.K. METHODS: For each female kidney, liver, or cardiothoracic organ transplant recipient who had had a recent pregnancy, data on maternal and fetal factors and pregnancy outcomes were collected using forms completed by their transplant follow-up and obstetric units. For kidney transplant recipients, the factors that influence pregnancy outcome were studied using logistic regression, and the effect of pregnancy on graft function was analyzed. RESULTS: There were live births in 83%, 69%, and 79% of pregnancies in cardiothoracic organ, liver, and kidney recipients, respectively. In 50% of live births from renal patients, delivery was preterm (<37 weeks), with 83% of the preterm infants delivered via caesarean. Preterm delivery was associated with maternal drug-treated hypertension and impaired renal function. A matched case-control study showed no evidence of increased renal allograft loss after pregnancy. A univariate survival analysis, however, suggested an association between drug-treated hypertension during pregnancy and poorer postpregnancy graft survival. In patients with prepregnancy serum creatinine (SCr) >150 micromol/L, a trend toward increased postpregnancy SCr was identified. CONCLUSIONS: Pregnancy is likely to end in a live birth in a majority of organ transplant recipients. In patients with greater prepregnancy SCr and/or drug-treated hypertension during pregnancy, however, subsequent renal function may be adversely affected.     

Study on the environmental background to aggravating factors for renal function related to pregnancy and delivery in IgA nephritis.

Various effects on renal function and factors which tend to cause aggravation in pregnancy and delivery in patients with renal diseases have been described previously. In the present study, the authors undertook personal and telephone inquiries to patients with renal insufficiency due to aggravated renal dysfunction occurring during the course of pregnancy and delivery, and to those showing a favorable course despite renal dysfunction before pregnancy. Sixty-four patients with IgA nephritis were investigated, covering 101 cases of pregnancy in them. The management of the pregnant women and their social and home (family/domestic) environments were taken into consideration, since these are important for giving guidance in their daily life to overcome various factors which influence the course of spontaneous pregnancy and delivery. The following findings were obtained. (1) In patients with hypertension, toxemia of pregnancy, abnormal delivery and abortion were frequently complicated. (2) Patients under greater mental and physical stresses during the course of pregnancy and after delivery showed a poorer prognosis for both mother and fetus. (3) Generally speaking, guidance should be given not to be overconfident or overdefensive in pregnancy. (4) Working women revealed a prognosis which was poorer than that of housewives.