Pregnancy in Renal Transplant Recipients

Susan Hou
Fertility in women with kidney failure is restored by transplantation. It requires careful planning and is only advisable in women
with good kidney function, controlled blood pressure, and general good health. Immunosuppressive drugs carry risks for the
fetus, but the risks of prednisone, azathioprine, cyclosporine, and tacrolimus are surprisingly low. Mycophenolate is terato-
genic. The success rate for pregnancy in kidney transplant recipients is lower than in the general population with 70% to
80% of pregnancies resulting in surviving infants. Prematurity, intrauterine growth restriction, and preeclampsia are all in-
creased. Complications are higher and outcomes are worse for women with serum creatinine levels over 1.3 mg/dL. Ten to
15% of women have a temporary or permanent decline in kidney function, particularly if prepregnancy creatinine is high.
Transplant-related infections can be serious for the mother and fetus. A multidisciplinary team should coordinate care.
Q 2013 by the National Kidney Foundation, Inc. All rights reserved.
Key Words: Pregnancy, Kidney transplant, Immunosuppressive drugs, Opportunistic infection

(NTPR), 11 in recipients of kidney transplants.3 It is not

O n March 10, 1958, the first woman to receive a kidney
transplant gave birth to the first baby born to a kid-
ney transplant recipient.1 She was transplanted from an
identical twin sister, thereby avoiding the problems of im-
munosuppressive drugs and associated infections in
pregnancy. However, this event led to a few important
new observations. Transplantation restored fertility in
women with kidney failure. The function of a solitary kid-
ney was sufficient to sustain pregnancy. The proximity of
the uterus to the transplanted kidney did not cause me-
chanical problems.
The potential for pregnancy raised a multitude of
questions about the effect of pregnancy on the trans-
planted kidney and the effect of kidney disease on the fe-
tus and on pregnancy-related complications. The kidney
transplant recipients whose pregnancies followed this
first woman were treated with immunosuppressive
drugs, with each new generation of drugs requiring eval-
uation for teratogenicity. All immunosuppressive drugs
put the women at risk for opportunistic infections that
can be devastating for the developing fetus.
Fertility in Transplant Recipients
Women treated with dialysis have markedly decreased
fertility (see ‘‘Changes in Fertility and Hormone Replace-
ment Therapy in Kidney Disease’’ in this issue); however,
kidney transplantation is usually accompanied by a re-
turn of fertility. Even women who have follicle stimulat-
ing hormone and luteinizing hormone levels in the
postmenopausal range may have normalization of levels
and restoration of fertility. The return of fertility is not
universal. Pietrzak and colleagues2 noted that only
68.1% of 63 kidney transplant recipients had regular
menstrual cycles whereas the rest had irregular cycles.
Ovulation was documented by rising progesterone and
ultrasound visualization of follicle growth in 59.5% of
women with regular menstrual cycles.
In vitro fertilization was used in 17 of 1134 pregnancies
reported to the National Transplant Pregnancy Registry
clear whether infertility is more common in kidney trans-
plant recipients than in the general population. Sirolimus
is known to decrease sperm counts and fertility in men,4
but its effect in women is unknown.
Counseling
The discussion about pregnancy and childbearing should
begin when a woman of childbearing age is seen for her
first pretransplant evaluation and continued after trans-
plantation. For those who are too young to be considering
pregnancy, the matter should still be mentioned and dis-
cussed again as the patient gets older. Part of counseling
includes emphasis on the need to continue immunosup-
pressive therapy. Without the explicit knowledge that
loss of graft function carries a higher risk for the baby
than the medications, some women have elected to stop
drugs on their own for fear of an adverse effect on the
baby. Counseling should also emphasize the need to
plan pregnancies because medications often need to be
changed before conception. Every woman treated with
mycophenolate products should be advised of and re-
minded of their teratogenic potential. Fully 26% of 440
pregnancies reported in an early survey in 1979 ended
in elective abortion, often because pregnancy was unex-
pected and viewed as dangerous.5
It is usually advised that a woman wait at least 1 year
before attempting conception. Many would prefer a wait
of 2 years but recognize that after a long wait for trans-
plant, the window of fertility may be narrow. The
From the Department of Medicine, Loyola University Medical Center, May-
wood, IL.
Conflict of Interest: S.H. owns stock in Amgen and talks about using eryth-
ropoietin in pregnancy.
Address correspondence to Susan Hou, MD, Loyola University Medical
Center, 2160 South First Avenue, Maywood, IL 60153. E-mail: shou@lumc.edu
Ó 2013 by the National Kidney Foundation, Inc. All rights reserved.
1548-5595/$36.00
http://dx.doi.org/10.1053/j.ackd.2013.01.011

Advances in Chronic Kidney Disease, Vol 20, No 3 (May), 2013: pp 253-259 253
254 Hou

guidelines that are used for advising transplant recipi- follow-up, graft survival was 77.8% in women who had
ents about pregnancy are listed in Table 1. become pregnant, 69.2% in the female controls, and
69.8% in the male controls (not significant). Twenty-
Outcome of Pregnancy in Kidney Transplant eight percent of pregnant women and 31% and 22% of
Recipients the 2 control groups used cyclosporine A (CsA). A case-
The NTPR is the largest body of information on preg- control report from the European Dialysis and Transplant
nancy outcomes in transplant recipients. Over its Association including 53 women who became pregnant
20-year history, the registry has collected data on 1490 matched with controls for year of transplant, type of
pregnancies (1525 outcomes) in 922 kidney transplant re- transplant, and serum creatinine found kidney function
cipients. Among the 666 women treated with calcineurin unchanged in case and controls in 67% and worse in
inhibitors (CNIs), 73.8% of the 1026 pregnancies (1066 both in 9%.12 In 15% of pairs, the control had a deteriora-
outcomes) resulted in live births.3 There were 12 neonatal tion of kidney function and in 9% the patient who became
deaths (1.1%). Other outcomes included 17.3% spontane- pregnant had a worsening of kidney function. Sturgiss
ous abortions, 4.5% therapeutic abortions, 2.5% were and Davison compared a group of 18 high-risk women
stillborn, and 0.6% were ectopic pregnancies.3 Other se- who had 34 pregnancies to a control group matched for
ries report similar results.6-9 In one recent report, only factors that affected kidney transplant longevity and
32 of 53 (60%) pregnancies in kidney transplant found no effect of pregnancy on graft survival.13 All of
recipients resulted in surviving infants, 69.5% if elective these series are limited by the inclusion of only a few
7 women with impaired kidney function and either a small
terminations are excluded.
Pregnancy in transplant recipients is also associated or unspecified number of women treated with CsA.
with a high rate of prematurity and intrauterine growth There is a single controlled study that suggests that graft
restriction. Of the NTPR function is adversely af-
pregnancies discussed fected by pregnancy. Sal-
above, 52% resulted in deliv- CLINICAL SUMMARY mela and colleagues
ery before 37 weeks gesta- reported long-term graft
3
tion. The frequency of  Fertility is restored in kidney transplant recipients. function in 22 female kidney
prematurity has remained  Successful pregnancy is likely in a woman with good transplant recipients with
fairly constant over time. kidney function and controlled blood pressure when 29 pregnancies compared
The severe prematurity that undertaken more than a year after transplant. with 38 female controls
we see in pregnant dialysis  Immunosuppressive drugs need to be modified for matched for cause of kidney
patients is less common. pregnancy. failure, kidney source,
immunosuppression, time
 Patients need close monitoring for changes in kidney
function and infection. from transplant, and serum
Effect of Pregnancy on
creatinine.14 CsA was used
Graft Function
during 9 pregnancies and 4
In 1985, Davison published had a prepregnancy serum
a report on prospectively studied kidney graft function creatinine of greater than 1.48 mg/dL. During the
during 10 pregnancies in 8 kidney transplant recipients.10 follow-up period, 8 of the women who became pregnant
All had creatinine clearances of greater than 50 cc/min, lost their grafts, 1 at 1 month postpartum. The other grafts
less than 250 mg/24 hours of protein, and well controlled were lost between 1 and 11 years postpartum, but in 3 the
blood pressure. There was a mean increase in creatinine deterioration of graft function began during pregnancy.
clearance of 30% by weeks 9 to 12 (range 10%-60%) de- At the 10-year follow-up, transplant survival was 100%
spite compensatory hypertrophy and increased function for the control group and 69% for the group who had
of the solitary kidney at the time of transplant. In 2 pa- pregnancies (P , .005). Graft loss could not be correlated
tients kidney function was lower than prepregnancy with elevated serum creatinine at the time of conception.
levels postpartum. Less is known about changes in glo- The difficulty generalizing from this study lies in the rar-
merular filtration rate in women with impaired kidney ity of centers with a 10-year kidney transplant survival of
function and in women who conceived in the era of CNIs. 100% such as was seen in the control group. The bulk of
There are several studies with case controls looking at the evidence suggests that graft function is usually not
the outcome of pregnancy on kidney graft function. First adversely affected by pregnancy in women with serum
and colleagues reported graft function in 18 women who creatinine less than 1.5 mg/dL treated with prednisone
underwent 25 pregnancies compared with 26 female con- and azathioprine.
trols and 23 male controls.11 Mean follow-up for the The long-term effect of pregnancy on kidney trans-
group who became pregnant was 11.8 years after trans- plant function is most influenced by prepregnancy kid-
plantation and 6.9 years after pregnancy with similar ney function. A woman who becomes pregnant with
periods of follow-up for the control groups. At last a serum creatinine of 1.4 mg/dL or less is unlikely to
 Pregnancy in Renal Transplant Patients
Table 1. Guidelines for Pregnancy After Transplant
1 y after transplant
Creatinine ,2 mg/dL (better #1.3 mg/dL)
No hypertension
No proteinuria
No recent rejection
No pelvicalyceal distension
Prednisone dose #15 mg/d
Azathioprine dose #2 mg/kg/d
CsA dose , 4 mg/kg/d
have long-term damage to the kidney. However, with the
use of CNIs, many women destined to have a functioning
graft for many years have serum creatinine levels above
1.4 mg/dL, and many have rephrased guidelines to allow
for prepregnancy serum creatinine levels as high as 1.9
mg/dL.
The data on the effects of prepregnancy kidney func-
tion on pregnancy complications come from a review
by John Davison of 3382 pregnancies in 2409 patients.
Pregnancy was successful in 96% of women with pre-
pregnancy serum creatinine levels of less than 1.4 mg/
dL and 75% in those with prepregnancy creatinine levels
of 1.4 mg/dL or greater.15
Management (see Table 2)
Deterioration of Kidney Function During
Pregnancy
Changes in kidney function during pregnancy are com-
mon, with 10% to 18% of women having transient or per-
manent worsening of kidney function. ‘‘Acute Kidney
Injury in Pregnancy—Current Status’’ is discussed sepa-
rately in this issue. Pregnant kidney transplant recipients
are at risk for the causes of kidney failure in other preg-
nant and nonpregnant patients. A few causes of deterio-
ration are specific for transplant. Rarely there is
obstruction of the transplant by the growing uterus,
a problem that can often be identified by ultrasound if
a first-trimester ultrasound is done for a baseline. If there
is a question, then antegrade nephrostogram may be nec-
essary. There are multiple possibilities for elevated CNI
levels causing kidney injury because of the need for
changing doses and the frequent introduction of other
drugs.
Acute rejection should be rare 1 year after kidney
transplant, but Armenti and colleagues noted rejection
in 14.5% of 154 pregnancies in CsA-treated women in
an early NTPR report.16 Rejection should be verified by
biopsy before treatment.
Preeclampsia may be difficult to differentiate from
other causes of elevated creatinine, but it may become
easier as measurements of antiangiogenic factors are bet-
ter understood. Hemolytic uremic syndrome can occur
from pregnancy or CNI and is discussed separately in
‘‘Acute Kidney Injury in Pregnancy—Current Status’’
255
Table 2. Approach to Pregnancy in Kidney Transplant Recipients:
Counseling Before and After Transplant About the Return of
Fertility and the Need to Plan Pregnancy
Before pregnancy
Stop mycophenolate 6 weeks before conception. Stop
sirolimus and everolimus. May substitute azathioprine.
Stop statins and ACE inhibitors.
Consultation with high-risk obstetrician.
24-h urine for protein and creatinine clearance.
Tests for antibodies to CMV, toxoplasmosis if negative in the
past.
PCR for CMV and toxoplasmosis.
Urine culture.
During pregnancy
Start low-dose aspirin.
The patient should start measuring blood pressure twice
daily.
Kidney ultrasound during the first trimester.
Measurement of CNI levels and complete metabolic profile
and CBC every week. Decrease measurement of CNI to
every 2 wk if levels are stable.
Urine culture and urine protein-to-creatinine ratio monthly.
24-h urine for protein and creatinine clearance; CMV and
toxoplasmosis PCR every trimester.
Assessment of fetal well being from 26 wk gestation.
Peripartum and postpartum
C-section only for obstetric indications.
Continue twice-daily blood pressure monitoring for 6 wk
postpartum.
24-h urine for protein and creatinine clearance 1 mo and 6 mo
postpartum.
Abbreviations: ACE, angiotensin converting enzyme; CBC, complete
blood count.
published in this issue. Rarely, recurrent disease causes
acute kidney injury.
Hypertension
Hypertension is very common in pregnant transplant re-
cipients. The use of antihypertensive medication and the
difficulty making the diagnosis of preeclampsia are dis-
cussed in ‘‘Management of Hypertension in Pregnancy’’
and ‘‘Emerging Biomarkers of Preeclampsia’’. There is de-
bate about the level of hypertension that should be treated
in normal pregnant women, but with the availability of
many antihypertensive drugs that are safe in pregnancy,
there is no reason not to treat any blood pressure of 140/
90 mmHg or more in a woman with a kidney transplant.
Anemia
Anemia is common in pregnant kidney transplant recip-
ients. Magee and colleagues found that 74% of a group of
pregnant transplant recipients had hemoglobin levels be-
low 10 g/dL compared with 13.5% of controls.17 For the
transplant recipient, anemia is likely to be multifactorial.
Even with mild chronic kidney disease, erythrocyte pro-
duction may not increase by the 30% to 40% seen in
normal pregnancy. Drugs may cause bone marrow sup-
pression or hemolysis, and transplant recipients are
256
also at risk for iron deficiency and for the hemolytic syn-
dromes associated with pregnancy (see ‘‘Acute Kidney
Injury in Pregnancy—Current Status’’ in this issue). Nor-
mal pregnancy requires 700 to 1000 mg of iron. If oral iron
supplementation is not sufficient, then ferric gluconate
has been labeled category B for pregnancy by the U.S.
Food and Drug Administration (FDA). Because of the
high rate of transfer to the fetus, especially after 30 weeks
gestation, we limit individual doses to 62.5 mg. Erythro-
poietin does not appear to be teratogenic. Most pregnant
dialysis patients have been exposed to it during the first
trimester. Radiolabeled erythropoietin has been shown
not to cross the placenta in sheep.18 In all patients with
kidney disease, there is an increased risk of stroke with
higher doses of erythropoietin. It seems reasonable to
start erythropoietin when the hemoglobin level is below
10 g/dL and after other factors have been corrected.
Immunosuppressive Drugs
The potential effects of immunosuppressive drugs on the
developing fetus have always been a concern for physi-
cians taking care of transplant recipients. New drugs
have come into use just as the risks of older drugs have
been assessed.
Prednisone
Prednisone has been widely used in various settings other
than kidney transplant, including asthma, idiopathic
thrombocytopenia, and systemic lupus erythematosus. It
poorly crosses the placenta. The ratio of maternal to cord
blood levels of prednisolone in late pregnancy is 8:1 to
10:1.19 Passage of the drug across the placenta early in
pregnancy may be higher. In the fully developed placenta
placental 11-beta-hydroxylase partially inactivates the
drug. Even with the poor passage of prednisone across
the placenta, high doses such as those used to treat rejec-
tion will result in substantial fetal exposure. However,
an infant who appears healthy at birth still needs to be
monitored for adrenal insufficiency. Prednisone increases
the risk of hypertension and gestational diabetes in the
mother. In doses over 20 mg a day, it has been associated
with increased risk for opportunistic infection and of pre-
mature labor.
Azathioprine
Azathioprine has been used by thousands of pregnant
women but has been labeled as a category D drug by
the FDA. The designation is based largely on malforma-
tions seen in animals given azathioprine parenterally in
higher doses than usually given to humans. Azathioprine
and the inactive metabolite 6-mercaptopurine poorly
cross the placenta. Maternal and fetal blood levels of
the active metabolite 6-thioguaninenucleotide are similar.
A prospective study by Goldstein and colleagues com-
pared the rate of birth defects in the infants of 189 women
Hou
receiving azathioprine with the infants of 230 healthy
controls.20 Rates were 3.5% in the azathioprine group
and 3% in the control group (not significant). There
were more preterm infants in the azathioprine group,
which was most likely the result of the underlying mater-
nal illness.
CsA
When CsA was introduced, it was already recognized
that prednisone and azathioprine presented acceptable
risks during pregnancy but that CsA was essential to pre-
venting rejection in many patients. It was established
early on that CsA crossed the placenta and resulted in fe-
tal exposure to CsA levels comparable to maternal
levels.21 The frequency of birth defects was comparable
to the general population (3%). Kidney function was
tested in a group of 22 children exposed to CsA in utero
between the ages of 6 and 72 months and was found to be
normal.22 Higher rates of prematurity and small-for-
gestational-age babies have been described with CsA
compared with azathioprine, but this finding is hard to
attribute to CsA alone.16 Drug levels may change with
forces acting to raise and lower levels. The changing
space of distribution may decrease the level whereas
the high levels of sex steroids may slow hepatic elimina-
tion of the drug.
Tacrolimus
There is not a clear advantage between tacrolimus and
CsA in terms of pregnancy risk. In a group of 21 women
(27 pregnancies) taking tacrolimus for liver transplants,
in 11 of 12 cases in which both maternal and cord blood
tacrolimus levels were measured, cord blood levels
were on average 36% of maternal levels.23 The placenta
appears to provide a barrier to tacrolimus with placental
levels being 2 to 56 times higher than cord blood and 4
times higher than maternal blood. Thirty-six percent of
infants had transient hyperkalemia and mild kidney im-
pairment.
Mycophenolate Mofetil and Mycophenolic Acid
Mycophenolate mofetil (MMF) was found to be associ-
ated with increased spontaneous abortions and congeni-
tal malformations soon after it came into use. In contrast
to other medications, MMF was found to embryotoxic in
animals in doses lower than those used in human. Mal-
formations described include microtia, cleft lip and pal-
ate, auditory canal atresia, hypertelorism, micrognathia,
ocular colombona, short fingers, and hypoplastic nails.24
A short 5th finger and hypoplastic nails were described
in the first case report of MMF use in pregnancy.25 The
NTPR’s 2011 report notes outcomes in 61 pregnancies
with exposure to mycophenolate products. There were
30 spontaneous abortions (49%) and 7 of 27 live-born
infants had characteristic congenital anomalies.3 The
 Pregnancy in Renal Transplant Patients
European Network of Teratology Information Service
prospectively followed 57 pregnancies. There were 16
spontaneous abortions and 12 elective abortions, includ-
ing 2 for congenital anomalies. Six of 29 live-born infants
had congenital anomalies.26 Enteric-coated mycophe-
nolic acid carries the same risk. The risk of congenital
anomalies with mycophenolate products is serious
enough that the FDA has placed a black box warning
alerting physicians to the risk of first-trimester use and
the company has instituted a Mycophenolate Risk Evalu-
ation and Mitigation Strategy that requires providers to
be educated about the teratogenicity of MMF and myco-
phenolic acid and to document that patients have been
educated about the pregnancy risks of the drug.
Sirolimus/Everolimus
Experience with mammalian target of rapamycin inhibi-
tors in pregnancy is very limited and there is reluctance
to use this category of drugs during pregnancy. Other ef-
fective immunosuppressive drugs have a track record of
relative safety during pregnancy. There are several case
reports of the use of sirolimus and one case report of
the use of everolimus during organogenesis without re-
sulting congenital anomalies.27-29 The NTPR 2011
Annual Report included 23 pregnancies with sirolimus
exposure; in the 3 instances in which congenital
anomalies were noted, the mother was also taking MMF.3
Belatacept
There is little experience with belatacept use during preg-
nancy, but its use will be a focus of data collection by the
NTPR in the next year.3
Antibodies
There is limited information on the use of monoclonal
and polyclonal antibodies during pregnancy. Waiting 1
year before conception has as 1 of its goals reducing the
risk of acute rejection and the need for antibody therapy.
All types of immunoglobulin G (IgG) cross the placenta
with increasing efficiency as pregnancy progresses with
the greatest chance of crossing being in the last 4 weeks
of pregnancy.
Although not usually used for treatment of rejection,
there are some data on the effect of rituximab, a hu-
man/murine chimeric monoclonal IgG directed against
the CD 20 protein, on B lymphocytes, which causes B
cell depletion. The timing of transfer of IgG would imply
a lower risk of congenital anomalies in women who re-
ceived rituximab in the first trimester, but the drug may
persist in the maternal circulation and has been reported
to cause hematologic abnormalities and predisposes to
infections, including cytomegalovirus (CMV). Women
are advised not to conceive for 1 year after receiving rit-
uximab.30
257
Plasmapheresis
Plasmapheresis has been used in several pregnancy-
associated conditions unrelated to transplant with ac-
ceptable risk.
Infections
Immunosuppression puts the pregnant woman at risk for
opportunistic infections that can have severe effects on
the newborn. Foremost among these is CMV. In the gen-
eral population, primary CMV infections are associated
with 3% to 40% transmission to the fetus and recurrent
infections are associated with 1% transmission. Transmis-
sion is less likely to occur early in pregnancy than late in
pregnancy, but the effects of the virus are more severe
when it is acquired early in pregnancy. If the mother is se-
riously ill with CMV, she should be treated with the best
antiviral drug available. The question remains of when to
treat for the benefit of the fetus when the mother is
asymptomatic. The diagnosis of intrauterine CMV infec-
tion is achieved by measuring CMV via polymerase chain
reaction (PCR) of the amniotic fluid, although there are
false negatives. One study reports a 13% incidence of
long-term sequelae of intrauterine CMV infection in in-
fants of women treated with CMV hyperimmunoglobu-
lin compared with 43% in infants of untreated
women.31 The dilemma of deciding about treating
asymptomatic CMV becomes more common when sur-
veillance PCRs for CMV are done during pregnancy.
Herpes Simplex
Herpes simplex is usually spread from mother to child
during birth rather than through intrauterine infection.32
Primary infection with herpes simplex virus-1 or herpes
simplex virus-2 during pregnancy in normal women car-
ries the risk of neonatal herpes only if infection occurs
close to the onset of labor.33 The risk of neonatal herpes
can be minimized by Caesarian delivery in women who
have a primary infection or reactivation of herpes. Reac-
tivation is associated with neonatal herpes only if the in-
fection occurs near term, but not if there is asymptomatic
cervical shedding of the virus. Acyclovir can be safely
used in pregnancy.32
Toxoplasmosis
Primary toxoplasmosis infection during pregnancy re-
sults in neonatal infection in 25% to 65% of infants.34,35
The frequency of neonatal infection increases with
increasing number of weeks gestation at the time of
infection, but the likelihood of severe manifestations
of the infection decreases with increasing length of
gestation. Infection in the fetus can be detected in 93% of
cases by a combination of testing amniotic fluid and fetal
blood and of visualization of ventricular enlargement
by ultrasound at 20 to 24 weeks.36 Treatment with
258
sulfadiazine and pyrimethamine or spiramycin reduces
the likelihood of congenital infection by 60%, and a pri-
mary infection should be treated even if the mother is
not seriously ill.37 Congenital infection occasionally oc-
curs after reactivation of toxoplasmosis in immunosup-
pressed patients, and consideration should be given to
treating seropositive women with rising antibody titers.
Pregnant kidney transplant recipients should be screened
for toxoplasmosis each trimester.
There are large bodies of literature on vertical infec-
tions that may be pertinent to transplant recipients, in-
cluding HIV, hepatitis B and C, and Trypanosoma cruzii,
and their management is beyond the scope of this paper.
Urinary Tract Infections
Urinary tract infections are by far the most common in-
fections affecting pregnant kidney transplant recipients,
up to 40% in some series. In normal pregnancy, it is
rare to see pyelonephritis in a woman with a negative
screening urine culture, but transplant recipients should
be screened monthly. Treatment of pyelonephritis is dis-
cussed in the article ‘‘Kidney Stones and Pregnancy’’ in
this issue.
Breast Feeding
Women with solid organ transplants are usually advised
not to breast feed after successful pregnancy. Moretti and
colleagues calculated daily CsA intake and measured se-
rum CsA levels in 5 infants who were breastfed. The cal-
culated CsA exposure was low, and in most infants the
CsA level in the infant was low or undetectable. How-
ever, one infant had near-therapeutic blood levels of
CsA.34 The NTPR Annual Report for 2011 reported breast
feeding of 126 infants (for a few days to 10 years) without
adverse effects.3 At this point, breast feeding has not
caused visible problems in the newborns, but more de-
tailed studies, particularly of immunologic development,
are needed. With the information available to date, we do
not strongly discourage breast feeding.
Conclusions
Kidney transplantation remains the best hope for suc-
cessful pregnancy in women with end-stage kidney dis-
ease, although results in dialysis patients discussed in
‘‘Dialysis and Pregnancy’’ in this issue are encouraging.
It is important to start counseling early and to have
planned pregnancies. The pregnant transplant patient
should be cared for by a multidisciplinary team, which
includes obstetricians, transplant nephrologists and sur-
geons, neonatologists, and pharmacists. The team should
also include the transplant nurses who have worked with
the patients and a social worker because pregnancy is
stressful even when the outcome is good. A level 3 nurs-
ery should be available for the care of the newborn be-
Hou
cause it may be required. The patients should be seen
once every 2 weeks throughout pregnancy and should
monitor blood pressures at home. Despite being the
best option for women with end-stage kidney disease,
the success rate is still only approximately 75%. With
wide application of what we already know, the outcome
can be improved. There are still elective terminations,
most of which can be avoided by counseling and planned
pregnancies. Many neonatal deaths are from prematurity,
which may be avoided with better diagnosis and treat-
ment of preeclampsia. Ironically, some questions such
as the toxicity of new drugs and the outcomes of breast
feeding will be known only when pregnancies are acci-
dental or when women elect not to follow our advice.
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