1. A 25-year-old lady who had her third kidney transplant 3 years ago with excellent function. She was kept on tacrolimus and steroids during her first pregnancy. USS scan showed viable foetus at 24 weeks of gestation and moderate hydronephrosis during the follow up (USS picture is shown below). One week later, her S Cr deteriorated (from 70 µmol/L to 115 µmol/L). Percutaneous nephrostogram (picture is shown below) demonstrated obstructed ureter properly by the foetal head.
- How do you manage her graft dysfunction?
- Would you advise normal delivery?
- If she requires CS, what are your precautions during the surgery?
Dear All
One surgical question, but it is common sense
If you were the surgeon, will do the C/S through
a Pfannenstiel incision or the old fashion lower midline incision?
Vertical incision preferred to reduce the risk of direct graft injury or sharing force
I will do it through a vertical midline incision to avoid direct or shearing forces on the transplant kidney.
_______________
Ref:
Catherine E. Gordon and Vasiliki Tatsis “Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature”.
https://dx.doi.org/10.1186/s12882-019-1281-6
Kidney transplants are typically positioned extra -peritoneally in the lower abdomen, which is in the operative field of a Pfannenstiel incision at the time of Cesarean section so there is also a risk of injury to the transplanted kidney at the time of Cesarean section. So preoperative organ mapping and better to plan about the type of surgical incision in this case preferred midline vertical incision to avoid the risk of indirect shearing force and avulsion of the transplanted kidney while elevating the underlying fascia due to previous multiple surgical adhesions . The presence of transplant surgeons team is mandatory as part of multidisciplinary approach to avoid such serious complication for the mother,fetus and the graft.
References:
1-Gordon, Catherine E, and Vasiliki Tatsis. “Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature.” BMC nephrology vol. 20,1 94. 18 Mar. 2019, doi:10.1186/s12882-019-1281-6
Lower midline incision.
Vertical midline incision
A surgical approach to the uterus during caesarean section through a midline incision, both on the abdominal wall and the uterus, as in a classic caesarean section, may be more appropriate in renal transplant recipients, particularly in patients with transplanted kidneys in both iliac fossae.
Rahamimov R, Ben-Haroush A, Wittenberg C, Mor E, Lustig S, Gafter U, et al. Pregnancy in renal transplant recipients: long-term effect on patient and graft survival. Asingle center experience.
Transplantation 2006; 81(5): 660-664
In common sense,
Vertical incision is preferred .
But at the end of the day (case by case management is the proper way).
midline incision is recommended in this case to avoid direct graft injury.
Pfannenstiel incision is in the region of transplanted kidney with a potential risk of damaging the kidney or its ureter, especially in the recurrent Cs. Nevertheless ,its not a contraindication to perform Pfannenstiel incision post kidney transplant. The Old incision is anatomically avoiding the transplanted kidney, and theoretically safer than the Pfannenstiel incision, however its associated with higher risk of rupture of the uterine wall in subsequent pregnancy and non advisable to perform.
Excellent All
I did Pfannenstiel incision, I found the ureter very close to my knife. I have learned to be vertical incision.
Vertical midline incision.
It is better, as there is less chance of graft injury
Thank you dear Prof. Ahmed
Here is a summary of an interesting paper.
· Renal allograft is retro-peritoneal in the lower abdomen (in the operative field of a Pfannenstiel incision at the time of C/S).
· A meta-analysis showed a 57% risk of C/S in KTX versus 32% national average. A cohort study in Norway showed an adjusted 4-fold increased rate of C/S in KTX patients compared to controls.
· Little available data describing risk of damage to the transplanted kidney & its management during C/S.
· Increased rates of C/S are commonly due to fetal mal-presentation or non-reassuring fetal heart rate tracings in indicated preterm deliveries.
· A multidisciplinary team should be involved delivery planning.
· The Transplant Surgery team should be present or readily available at the time of delivery.
· Ideally, the Transplant Surgery team should be consulted in the antepartum period to assist with surgical planning, with consideration for pre-operative imaging to confirm transplant location.
· No specific recommendations exist to on how to prevent graft injury during C.S.
· Limited data on the appropriate skin incision. at the, only one retrospective cohort described incision type.
· Fang et al. described 22 patients with single kidney transplant or SKP transplants. 16 deliveries were by C/S, 15 of which were via a Pfannenstiel incision. 2 cases were complicated by cystotomy in the SKP group, while all single kidney transplant C/S via Pfannenstiel incision were uncomplicated.
· Farr et al. describe 12 ultra-high-risk pregnancies, of which 8 underwent C/S, all of which were uncomplicated except one which required hysterectomy due to placenta percreta.
· Mohammadi et al. describe uncomplicated C/S in 28 out of 35 pregnancies in patients with KTX.
· Neither of the above 2 studies describe the incision type, but assuming routine Pfannenstiel incisions were made in some, if not most, of these patients, then the complications rate appears low.
· Careful preparation for C/S in KTX patients is important.
· Providers should read the operative report from the transplant surgery to be familiar with the anatomy & any potential complications, such as dense adhesions noted on previous abdominal entry.
· At least transabdominal U/S should be done to localize the kidney prior to surgery, either formally or at bedside. MRI considered if U/S is limited or if better visualization is needed, such as assessing for abnormal placentation.
· C/S in the setting of KTX should only be performed for obstetrical indications.
· Surgeons should collaborate with the Transplant Surgery team.
· It is important to understand the anatomy of a TX kidney to decrease the risk of ijury, the renal vessels are anastomosed to the iliac vessels, either the common iliac or external iliac artery & vein, & the ureter is connected to the bladder from the iliac fossa.
· If a TX kidney is injured during C/S, profuse bleeding can occur & lead to maternal hemodynamic instability. Direct pressure should be applied to prevent massive blood loss, blood products should be administered as needed, & immediate repair of the injury is indicated.
Conclusion
TX kidney is often present in the pelvic retroperitoneal space
The location of the graft should be well identified via U/S or MRI & then carefully plan the incision.
A vertical midline incision can be considered to avoid injury to graft, especially in the setting of previous
surgeries with dense adhesions.
Early planning & close coordination between teams is needed to prevent complications to the fetus, mother, & the kidney.
Reference
Catherine E. Gordon and Vasiliki Tatsis
Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature BMC Nephrology (2019) 20:94
https://doi.org/10.1186/s12882-019-1281-6
Mid line vertical incision because the graft is hydronephrotic a little bit large so to avoid the injury
Old fashion lower midline incision is preferable than Pfannestiel incision due to reduce risk of ureteric injury
pfannestiel incision difficult and risky but not impossible need expert surgeon .but prefered safe approach lower midline incision
The vertical midline incision is safer, to avoid the risk of indirect shearing force and avulsion of the graft.
A vertical incision is preferred.
A Pfannensteil incison runs the risk of injury to the transplanted kidney. The graft is usually placed pre-peritoneally in the lower abdomen, and this site is directly in the operative field of a Pfannenstiel incision at the time of Cesarean section. There may be formation of adhesions with the graft adherent to the overlying anterior abdominal wall.
However, reports of Pfannensteil incisions have been made, with no complications following the surgery.
It is advised that pre operative planning involving organ mapping and incision planning be done before the Ceaserean Section; with consideration for a vertical midline incision to avoid direct or shearing forces on the transplant kidney. There shoudl also be a collaboratoipon with the transplant surgery team pre operatively, intimating them and ensuring they are available in case of an emergency or incase there is a need for intraoperative consultation.
References
Gordon, C.E., Tatsis, V. Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature. BMC Nephrol 20, 94 (2019). https://doi.org/10.1186/s12882-019-1281-6
vertical incision to avoid transplanted uerter in a Pfannenstiel incision
preferred midline incision to avoid graft injury
Lower midline to avoid graft and ureteric injury
actually there is no study comparing this two type incisons in kidney transplantation. there is studies with a pfannenstiel incision with good outcome in contrast there is acase report of kidney avulsion during traction of fascia. to be on safe side the preferd incision is lower midline incision .
Gordon, Catherine E, and Vasiliki Tatsis. “Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature.” BMC nephrology vol. 20,1 94. 18 Mar. 2019, doi:10.1186/s12882-019-1281-6
Lower midline vertical incision will be safer to avoid direct injury of the graft or it’s ureter, so it is more preferred than pfannenstiel one.
Vertical incision to avoid injury to the transplanted kidney and its ureter
Through lower midline incision to be away from the graft and to avoid tearing forces
1) How do you manage her graft dysfunction?
Urgent nephrostomy tube to relief the urinary tract obstruction
check DSA, CMV, BKV PCR,
FK level. Adjust Tac according to FK level.
2) Would you advise normal delivery?
Yes
3)If she requires CS, what are your precautions during the surgery?
Vertical incision to prevent iatrogenic renal graft injury.
percutaneous nephrostomy to be inserted first to relieve obstruction, then ureteric stent should be fixed.
Yes, normal labour is the rule but , c. section may be needed if any fetal complications occur.
Mid-line incision Good hydration and avoid Hypotension intra-operatively and give stress dose Corticosteroids , prophylaxis antibiotics.
How do you manage her graft dysfunction?
It is case of obstructive uropathy need drainage by per-cutaneous nephrostomy and insertion of DJ in the ureter
Would you advise normal delivery?
normal vaginal delivery unless there is an obstetric indication for CS
If she requires CS, what are your precautions during the surgery?
as the allograft is often placed extra-peritoneally in the iliac fossa , there is risk for injury at the time of CS
so pre-operative incision planning is needed with consideration for a vertical mid-line incision to avoid direct or shearing forces on the allograft
Patient with acute kidney injury due to uretric obstruction due to obstructive uropathy
Insertion of percutanous nephrostomy tube guided by ultrasound to save and preserve graft
Relief of obstruction will decrease pressure and so kidney function return back to normal
For more of delivery, vaginal delivery is the role unless there are obstetric complication present but under care of multidisciplinary teams
Prophylactic antibiotics to protect against infection and sepsis
With stress dose of corticosteroids
How do you manage her graft dysfunction?
This is a case of obstructive uropathy due to ureteric obstruction by the fetal head. Urgent relieve of obstruction should be achieved to save the graft, via temporary percutaneous nephrostomy draining of the graft with insertion of double J stent to keep patency of the ureter.
Would you advise normal delivery?
Normal delivery is advisable in KTRs unless there’s an indication for C/S.
If she requires CS, what are your precautions during the surgery?
At preparation for C/S, this lady with kidney transplant needs a team collaboration. The team consists of Obstetrician, Nephrologist, Transplant surgeon, Urologist and neonatologist.
During surgery:
· Adequate hydration to be maintained.
· Shifting oral steroids to IV hydrocortisone.
How do you manage her graft dysfunction?
It’s a case of post renal AKI mostly due to obstruction of graft ureter so relieving of the obstruction is the first step either percutaneous nephrostomy tube or ureteric stent.
In addition to that exclusion of other causes must be excluded so Immunosuppressant levels, urine analysis, urine culture and sensitivity, albumin/creatinine ratio, CMV, BK virus, and renal duplex.
Would you advise normal delivery?
Expected delivery is the preferred modality of delivery however obstetric assessment and the Pelvic US to detect the position of the fetus or presence of co-morbidities before labor if there are any indications for CS or any contraindications for normal delivery must be done in the last weeks in the third trimester.
If she requires CS, what are your precautions during the surgery?
MDT of ( Obstetrician, Nephrologist, urologist, and Anaesthologist ) for discussing the risk of injury of allograft during dissection of anterior abdominal walls in midline incision, the preferred incision is classic lower midline incision to avoid injury of kidney allograft especially if there were transplants on both sides
prophylactic antibiotic is needed
stress dose of hydrocortisone before operation and in the first-day post-CS.
Good hydration with Iv fluids before and after CS
close follow-up of blood pressure and blood sugar post-CS with early mobilization
management of her graft dysfunction:
normal delivery is the best if no obstetric indications
if Cs is needed so we should do the following precautions:
perform an ultrasound in the third trimester to confirm the anatomic location of the graft in the setting of the gravid uterus. This information should be placed in the prenatal record to guide the surgeon if a cesarean delivery is required. Prophylactic antibiotics are warranted to avoid complications in these immunocompromised patients.
How do you manage her graft dysfunction?
A case of obstructive urology for urological consultation for ureteric stent or nephrostomy tube.
Would you advise normal delivery?
Vaginal delivery is not contraindicated in transplant patients and is always the preferred one. Caesarean is indicated for obstetric indication only.
If she requires CS, what are your precautions during the surgery?
Shift steroid to hydrocortisone 100mg q6 hrs IV.
MDT approach, obstetrician, urologist, transplant surgeon, and neonatologist.
1. From the provided data , case presented with AKI together with picture of obstructed ureter with fetal head in nephrostogram, so the most likely etiology is post renal AKI with hydroureteronephrosis, so the immediate management should be US guided percutaneous nephrostomy to relieve tension and preserve the kidney tissue. However, this may be just immediate temporary management and double J ureteric stent may be needed till end of pregnancy.
_ release of pressure and obstruction should be followed by good urine output and normalization of creatinine. If that didn’t occur, investigations to exclude UTI as urine analysis and culture , virology as CMV and BK would be requested. Even graft biopsy may be needed.
2. As regard the mode of delivery, vaginal delivery is the rule except in presence of obstetric indications of CS. However, multidisciplinary team discussion and decision making including transplant surgeon, nephrologist and obstetrician is needed to choose the best option in such critical or complicated case with prior 3 transplantation operations and obstructed hydronephrosis.
3. Precautions in CS in such patient:
a. Incision…we may prefer lower vertical midline incision to avoid injury of the graft and it’s ureter
b. Prophylactic antibiotics is needed to prevent purperal sepsis and surgical wound infection and delayed wound healing.
c. Stress dose steroids (IV hydrocortisone in the morning prior to elective CS then 25 mg every 6 h for 1st 24 hours.
· How do you manage her graft dysfunction?Investigation showed obstruction due to fetal head nephrostomy tube should be placed until delivery .
· Would you advise normal delivery? If there is no obstetrical complication vaginal delivery can be perform .
· If she requires CS, what are your precautions during the surgery? Pfannensteil incision is not prefer because injury to the graft and its ureter so mid line incision is safe .
·
1- How do you manage her graft dysfunction?
The history and investigation suggests obstructive uropathy as a cause of graft dysfunction .therefore the first step is to treat the obstruction . but the other causes of graft dysfunction should be kept in mind if no response after relieving obstruction which include ( hypovolemia –although no history of hyperemesis gravidarium –viral infection CMV-BKV, rejection ,CNI toxicity) should be carefully excluded. Obstructive uropathy can be treated effectively and safely by percutaneous nephrostomy and ante grade stenting .
2- Would you advise normal delivery?
Yes , the normal vaginal delivery is the preferred and recommended way of delivery in post kidney transplant patient . but C/s can be done according the usual obstetrical indications.
3- If she requires CS, what are your precautions during the surgery?
This patient needs multidisciplinary team work involving ( transplant surgery team ,obstetrician, nephrologist, anesthesiologist ). And to be very careful to avoid graft avulsion ,laceration and trauma .
To a decrease the chance of graft damage I suggest to use the old a lower midline incision rather than the commonly used pfannenstiel incision.
Increase the dose of steroid and change it to injectable steroid (equivalent doses of hydrocortisone ), close monitoring of hemodynamic state , urine output , renal function.
References
Pappas P, Giannopoulos A, Stravodimos KG, et al. Obstructive uropathy in the transplanted kidney:definitive management with percutaneous nephrostomy and prolonged uretral stenting. Endourol[Internet]. 2001;15(7):719_23 Available from;
http://dx.doi.org/10.1089/08927790152596316
graft mapping before C/S by ultrasound or even by MRI is important to avoid graft damage .
dropped GFR is because of obstruction related to fetal head, so the best action is to insert a nephrostomy in the renal graft to relieve obstruction till delivery happens.
normal vaginal delivery is usually encouraged unless there is an obstetric indication.
Precautions: avoid injury to the renal allograft and its ureter and better to go of midline suprapubic incision instead of usual pfannensteil incision.
How do you manage her graft dysfunction?
Apparently, it’s post renal due to ureter obstruction. Nephrostomy would be the most indicated at the moment to improve renal function. Complementary investigation with CNI serum levels and viral panel should be considered.
Would you advise normal delivery?
Yes, normal delivery is the best option.
If she requires CS, what are your precautions during the surgery?
I would perform a vertical incision to avoid injuries to the ureter and other structures.
How do you manage graft dysfunction?
Normal physiological dilatation of the urinary system starts during the second trimester resulting in compression of the transplanted ureter between the fetal head and the pelvic brim.
However, In this scenario, there is obstructive Nephropathy with hydro-uretronephrosis resulting in AKI.
A multidiscipline approach is required involving nephrology, Urology and obstetric and IR opinions.
Management requires relieving the obstruction by a PCN under US guidance with treatment of any underlying UTI. After stabilizing renal functions, a ureteric stent can be inserted.
It is also important to exclude other causes of AKI including UTI, viral infections like CMV and BK virus which is a common cause of ureteric stenosis, Calcinurin nephrotoxicity, preeclampsia and rejection episodes
If no obvious cause can be identified and serum creatinine remains high , renal biopsy to be considered.
Would you advise normal delivery?
Again the decision requires obstetric opinion as normal vaginal delivery is the preferred modality unless there is an obstetric indication. we should also keep in mind that this is the third transplant and there may be no enough space to allow for normal vaginal delivery.
If we require CS, what are the precautions during delivery?
Delivery requires the help of transplant surgeon for perfect localization of the transplanted graft anatomy to avoid injury of graft, ureter and important vascular structures. This will occur in liaise with the nephrology, obstetric and anesthesia teams.
The patient will be counseled at that time about the indications for CS for the safety of herself and the baby in view of the complexity of her condition
A mid line Vertical incision is preferable than the usual pfennestiel to avoid ureteric injury. Ureteric stent may help in localizing the ureter position.
Stress corticosteroid dose before delivery and may be a prophylactic antibiotic dose if required
Good care of the wound and healing process as the patient is on immunosuppression
References:
How do you manage her graft dysfunction?
The patient undergone 3 renal transplants with excellent graft function at baseline and got pregnant after 3 years, Her medications were compatible with pregnancy
Moderate hydronephrosis is expected in pregnancy. But in the presence of kidney dysfucntion and moderate hydronephrosis, mechanical obstructions need to be ruled out.
Immediate Usg and nephrostomy should be carried out to get relieve the obstruction.
Meanwhile, the common causes of AKI post transplant should also be screened, such as CNI level, although usually lower in pregnancy, CMV,BKV,pre renal causes of AKI, DSA level and Urine FEME and Culture and sensitivity
For this patient, it is mechanical obstruction, so, percutaneous nephrostomy and antegrade DJ stent insertion should be the reasonable approach.
Would you advise normal delivery?
In a pregnant KTR, a normal vaginal delivery should be the first choice and caesarean section should be done only in emergencies or obstetric indications. Due to her multiple ransplant, it would be better to do midline surgical excision.
If she requires CS, what are your precautions during the surgery?
This case requires multidisciplinary discussion for the best method for delivery. Transplant surgeon, transplant nephrologist, obstetrician, and urologist should hold a discussion prior to operation.
A careful midline skin incision approach should be employed.
Antibiotic prophylaxis and stress dose steroids should be initiated.
Measure of reducing the event hypotension and infection should be taken.
How do you manage her graft dysfunction?
his 24 weeks pregnant lady presented with AKI with one week earlier US relieving moderate hydroureter .
management plan:
1- Relive the obstruction with percutaneous nephrostomy.
2- Urine analysis , C &S to treat any current infection
3- Exclude other causes of AKI as
a- Exclude preeclapsia, GDM
b- Assess proteinuria level
c- Sepsis screen
d- CMV , BK PCR
e- CNI trough level
Would you advice normal delivery
Normal delivery is the safest delivery mode in transplant recipients unless CS is indicated for obstetric reasons. for this lady, percutaneous nephrostomy should be followed up , changed every 4 weeks till delivery and try vaginal delivery if wasn’t CI at this time.
If CS is required :
1- Preoperative US to assess the anatomy of the graft, its vascular supply and ureter position. Insert ureter stent to avoid its injury, midline incesion to avoid graft injury.
2- Consider stress dose steroid, if she was on high dose prednisolone
Dear Dr Farag
This is a copy and paste from a colleague’s reply. This is very unethical; therefore, you have been referred to the Academic Integrity officer for investigation. Please see below:
Fatima AlTaher
8 days ago
this 24 weeks pregnant lady presented with AKI with one week earlier US relieving moderate hydroureter .
management plan:
1- Relive the obstruction with percutaneous nephrostomy.
2- Urine analysis , C &S to treat any current infection
3- Exclude other causes of AKI as
a- Exclude preeclapsia, GDM
b- Assess proteinuria level
c- Sepsis screen
d- CMV , BK PCR
e- CNI trough level
Would you advice normal delivery
Normal delivery is the safest delivery mode in transplant recipients unless CS is indicated for obstetric reason. for this lady , percutaneous nephrostomy should be followed up , changed every 4 weeks till delivery and try vaginal delivery if wasn’t CI at this time.
If CS is required :
1- Preoperative US to assess anatomy of the graft , its vascular supply and ureter position. Insert ureter stent to avoid its injury , midline insetion to avoid graft injury.
2- Consider stress dose steroid , if she was on high dose prednisolone
The patient is having her 3rd transplant with excellent graft functions…she is on tacrolimus and steroids with no other teratogenic drugs…She has developed graft dysfunction with recent increase in her creatinine with a PC nephrostogram showing obstruction by the fetal head…In pregnancy due to increased progesterone there would be physiological dilatation of the ureters, but when this is causing graft dysfunction this needs to be intervened…
I would go for Percutaneous nephrostomy with antegrade DL stenting and see if the graf tfunction improves….I would simultaneously send for urine culture and be sure not to miss or treat an acute pyelonephritis….If the graft function doesnt improve i would look at pre renal factors namely volume depletion, urosepsis, tacrolimus level, urine BK virus levels…If all the above are normal it is better to do the graft biopsy to ascertain the reason of graft dysfunction….As she has 3 kidneys USG guided imaging and biopsy would be challenging and high risk and it needs to be done with expertise…
Normal vaginal delivery should be the method of choice for all pregnancies…In this case if the patient does not develop any HTN and the fetus growth is normal by regular antenatal scans, I would recommend normal vaginal delivery….The presence of the nephrostomy tube which requires constant change maybe difficult for normal delivery, in which case CS option should be discussed with the patient…
CS would be risky in her as she has had already 3 surgeries..This would lead to weakness of the abdominal tissue and prone for hernias and delayed wound healing and infection….The vertical incision is preferred instead of the lower abdominal incision…If this is difficult for the OBS, detailed discussion with them has to be done to educate the about the anatomical position of the kidneys with their blood vessels…
1.How do you manage her graft dysfunction?
The cause of the graft dysfunction is the obstruction caused by the fetal heads’ pressure on the ureter. A percutaneous nephrostomy is to be placed, and the renal function monitored. An improvement is expected with reduction in the serum creatinine levels.
If however, renal function keeps deterioating then a renal biopsy will be done to determine the cause.
2.Would you advise normal delivery?
If there is no medical indication for a Ceaserean section, yes, i would advise a vaginal delivery. Vaginal delivery seems safer to these category of patients because of the risks asociated with abdominal delivery.
Experts state that the allograft location is not likely to experience damage during labour and vaginal delivery. Also, from folow up, it was found that vaginal delivery was associated with lower rates of neonatal composite morbidity; and in kidney transplant recipients, a trial of labor—whether or not it ended in a successful vaginal delivery—was associated with a lower rate of neonatal composite morbidity compared with a scheduled cesarean delivery.
3.If she requires CS, what are your precautions during the surgery?
The precautions during surgery are the avoidance of the graft, the vessels, and the grafts’ ureter. The renovascular and ureter anastomoses are situated in a site that is clearly in the lie of surgery during a Pfannenstgeil incision
References
Ozlü T, Dönmez ME, Dağıstan E, Tekçe H. Safe vaginal delivery in a renal transplant recipient: A case report. J Turk Ger Gynecol Assoc. 2014;15(2):125-127. Published 2014 Jun 1. doi:10.5152/jtgga.2014.45389
Yin O, Kallapur A, Coscia L, et al. Mode of Obstetric Delivery in Kidney and Liver Transplant Recipients and Associated Maternal, Neonatal, and Graft Morbidity During 5 Decades of Clinical Practice. JAMA Netw Open. 2021;4(10):e2127378. doi:10.1001/jamanetworkopen.2021.27378
Roman AS. Pregnancy After Transplant—Addressing Mode of Obstetrical Delivery Among Solid Organ Transplant Recipients. JAMA Netw Open. 2021;4(10):e2127414. doi:10.1001/jamanetworkopen.2021.27414
🍁 this is most probably a case of obstructive uropathy that needs A nephrostomy tube and a Ureteric stent may be required
But still we have to exclude other causes of Graft dysfunction especially during pregnancy such as rejection , UTIs , pre-eclampsia, other infections
🍁Vaginal delivery is always the preferred method of delivery unless there is obstetric contraindication .
🍁If CS is required we need to perform USS to check for place of the graft and ureter position , we may also need to get an access to the Tx surgeon records for more details , as well as steroid stress dose may be required if the labour was predicted to be a stressful one or the patient was on a high steroid dose .
How do you manage her graft dysfunction?
This lady is presented with graft dysfunction
That was explained by ureteric obstruction caused by foeral head
-Nephrostomy may help to reduce obstruction with follow-up of graft function.
-trough tacrolimus and virilogy work up,Glucose tolerace cureve, urine analysis, proteinuria, Bp all must be checked to ensure that no other factors affecting the geaft
Would you advise normal delivery?
normal delivery is advised in renal transplanted patients but in this case CS is advised after consultation of obstetric and urology team.
As this is 3rd transplantation, adhesions from previous surgery ,location of the graft and skin condition all must be considered while taking the decision.
If she requires CS, what are your precautions during the surgery?
Explaine the risk and benefits of Cs in her case ,with a written consent.
Avoid bleeding and variations in blood pressure ,keep good hydration .
Incision to be decided by obstetric and urology team according to site of the graft .
Vertical Midline incision may be preferred to avoid injury of the graft
Proper prophylactic antibiotics and care about wound infections.
1. How do you manage her graft dysfunction?
· Based on her clinical data the most probable diagnosis is Obstructive Uropathy by the foetal head (Ureteral compression due to a gravid uterus).
· So suitable management after exclusion of other causes of acute graft dysfunction is to relief the obstruction ,nephrostomy and nephrostogram
· Management should be multidisplinary including urology surgeon, nephrologist and transplant surgeon.
· Follow up for:
Kidney functions
Renal chart
Urine analysis
Blood pressure
Medications level and
Foetus.
2. Would you advise normal delivery?
· Normal vaginal delivery without abdominal compression is safe if the pelvic outlet measuring is reasonable and the patient stable.
3. If she requires CS, what are your precautions during the surgery?
· Pre-operative planning and close coordination between teams is fundamental to prevent complications to the mother, transplant kidney and foetus.
· Identification of the location of the transplant graft guided by ultrasound or MRI directed the decision toward the suitable incision.
· Vertical midline incision mostly preferable to avoid graft injury in the setting of previous surgeries with dense adhesions.
How do you manage her graft dysfunct
It’s obestructive uropathy by the fetal head but other causes of graft dysfunction must be excluded as Drug level , urine C/S , PCR for BK virus.
The first step is to relief obstruction by Nephrostomy or DJ which give better chance of avoiding ureteric injury during labor .
Would you advise normal delivery?
yes , normal vaginal delivery is recommended to avoid graft injury
If she requires CS, what are your precautions during the surgery?
Better , the renal transplant surgeon to be near if they need his help also DJ is advised to avoid any ureteric injury
1- Middle line incision
2-Good hydration .
3-Give stress dose of steroid .
Although the cause of AKI here is mostly obstructive uropathy , it might be worthy searching for other causes [ Renal & pre renal ] ( whether as the main cause or superadded one ) . first the patient need bed rest with positioning on the opposite side of transplanted kidney . then considering the USS diagnosis of asssumed obstructive uropathy then she needs drainage with either ureteric stenting or Percutaneous nephrostomy . Monitor her UOP and RFT closely , if things are getting better then keep a watchful approach , if slow or no improvement at all then consider other causes ( even a biopsy might be warranted )
If it turns to be a pure obstructive uropathy & the obstruction is dealth with properly , then NVD might be attempted but with preparatoins to switch to CS as indicated obstetrically ( may include stress steroid doses )
to avoid hitting the dialated ureter
avoid further kidney injury ( volume depletion , nephrotoxic medications
How do you manage her graft dysfunction?
Would you advise normal delivery?
If she requires CS, what are your precautions during the surgery?
1- Pregnancy in this patient is a great risk that this is the third kidney transplant.
As the percutaneous nephrostogram revealed obstructed ureter, nephrostomy tube may need to be inserted by urologgy team.
Investigations to rule out rejection, infection and tacrolimus toxicity.
2-I think cesserian cesection is a better choice.
a longitudinal incision.
3- A mutidisciplinary team work including neonatologist, obsteterician, transplant surgeon and nephrologist.
How do you manage her graft dysfunct
pregnant with allograft dysfunction
according to US report obstructive uropathy first in the differential diagnosis but such diagnosis really challenging since pregnancy cause significant degree of ureteral dilatation so percutaneuos nephrostomy highly recommended as diagnostic and therapeutic first line in management .
meanwhile we should search for other cause by send for drug level ,drug adherence ,viral screening ,intravascular volume assessment and if there is no cause we should arrange for renal biopsy to exclude rejection .
Would you advise normal delivery?
the best method labor in general for kidney recipient female is normal vaginal delivery so we should encourage for that but this decision should done not just by nephrologist (by multidisciplinary team) and in this case surgery may indicated due to obstructive uropathy .
If she requires CS, what are your precautions during the surgery?
1- surgery may cause trauma to transplanted kidney or ureter so collaboration with transplant surgeon and anesthesia team needed .
2- adjustment immunosuppressive drug may be difficult( prolong fasting and ileus and consciousness).
3-maintain well hydration state .
4- avoid nephrotoxic medication .
5- steroid dose may need to increase (stress dose).
How do you manage her graft dysfunction?
Most likely she has obstructive uropathy as evident by the ultrasound and so she needs urological consultation considering the possibility of Ureterorenoscpy (1) or use of percutaneous nephrostomy tube to relieve the obstruction. Perform Whitaker test after delivery to confirm resolution of obstruction by the gravid uterus.(2)
Other causes should be looked for like rejection and infection. So we need to check her TAC level , revise her compliance and viral screen for BK.
This patient must be referred to a tertiary obstetric centre with multidisciplinary expertise in prenatal and postnatal management of obstructive uropathies (3)
Would you advise normal delivery?
No, because she has obstructive uropathy which is an indication for C/S.
If she requires CS, what are your precautions during the surgery?
Proper counseling
Good hydration pre and peri-operatively
During surgery: Midline incision , ureter stent and stress dose of steroid
1. Bañón Pérez VJ, Rigabert Montiel M, Nicolás Torralba JA, Valdelvira Nadal P, López Cubillana P, Server Pastor G, Prieto González A, Pérez Albacete M. Manejo de la uropatía obstructiva en el embarazo [Management of obstructive uropathy in pregnancy]. Actas Urol Esp. 1999 Mar;23(3):227-31. Spanish. PMID: 10363379.
2. vanSonnenberg E, Casola G, Talner LB, Wittich GR, Varney RR, D’Agostino HB. Symptomatic renal obstruction or urosepsis during pregnancy: treatment by sonographically guided percutaneous nephrostomy. AJR Am J Roentgenol. 1992 Jan;158(1):91-4. doi: 10.2214/ajr.158.1.1727366. PMID: 1727366.
3. Capone, V., Persico, N., Berrettini, A. et al. Definition, diagnosis and management of fetal lower urinary tract obstruction: consensus of the ERKNet CAKUT-Obstructive Uropathy Work Group. Nat Rev Urol 19, 295–303 (2022). https://doi.org/10.1038/s41585-022-00563-8
How do you manage her graft dysfunction?
First of all I will consult the surgeon to ask about his opinion in this such hydronephrosis is it for stanting or not
Then I will investigate my medical cause like UTI,BK and CMV screening,control the blood pressure and CNI level
Would you advise normal delivery?
No ,in this case due to hydronephrosis
If she requires CS, what are your
precautions during the surgery?
Modified midline vertical incision and steroid stress dose
How do you manage her graft dysfunction?
Normal physiological changes that occur during pregnancy including ureteral dilatation and hydronephrosis. Acute rejection has been considered rare during pregnancy due to the fact that pregnancy is an immunomodulatory state.
In this case the exact reason for acute graft dysfunction due to obstructive uropathy due to fetal head compression, so the plan of management is a percutaneous nephrostomy tube under ultrasound guidance or ureteral stenting. And regular follow-up or renal function If renal functions still rising, a graft biopsy cane be done looking for feature of graft rejection. (1)
Would you advise normal delivery?
– Vaginal delivery is the preferred route of delivery and cesarean section is indicated only for obstetrical indications. But in this case it’s advisable to do CS through vertical midline incision to avoid injury to graft, especially in the setting of previous surgeries and also to avoid direct or shearing forces on the transplant kidney.
If she requires CS, what are your precautions during the surgery?
Pregnancy in renal transplant recipient is high risk and should be managed by a multidisciplinary team including obstetrician, neonatologist, transplant surgeon and transplant nephrologist.
Ideally, the Transplant Surgery team should be consulted in the antepartum period to assist with surgical planning, with consideration for pre-operative imaging to confirm transplant location.
of the transplant graft via ultrasound or MRI and carefully plan the incision. Providers can consider a vertical midline incision to avoid injury to the transplant organ, especially in the setting of previous surgeries with dense adhesions. Early pre-operative planning and close coordination between teams is imperative to prevent complications to the fetus, mother, and transplant kidney.
REF
1. Shobhana Nayak-Rao. Obstructive nephropathy in a post-transplant pregnancy. Year: 2016 | Volume: 27 | Issue: 6 | Page: 1290-1292.
2.Catherine E. Gordon and Vasiliki Tatsis “Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature”.
https://dx.doi.org/10.1186/s12882-019-1281-6
3. Shrestha BM, Throssell D, McKane W, Raftery AT. Injury to a transplanted kidney during caesarean section: a case report. Exp Clin Transplant. 2007 Jun;5(1):618-20. PMID: 17617055.
Management of graft dysfunction in this lady:
1. Nephrostomy insertion is considered a safe intervention to release obstruction till labor after proper counselling of the patient.
2. Monitoring of immunosuppression regimen and patient adherence to treatment.
3. Careful monitoring of renal functions, drug level, urine analysis and urinary cultures if needed.
4. Screening for other possible causes associated with deterioration of cr in this patient (e.g. CMV infection or BK nephropathy).
Decision of delivery:
Although normal delivery is the recommended mode of delivery in renal transplant recipients, and CS is only decided by the obstetric team but in this case a multidisciplinary approach is a must including urologist, nephrologist, anesthesiologists
and obstetrics as well to avoid any complication for each mother, baby and graft.
And of course after counselling the patient properly and taking her consent.
In case of CS delivery:
· Counselling the patient and her partner for the risks and benefits according her case.
· Adequate hydration and hemodynamic stability should be ensured.
· Adequate immunosuppression is a must with close monitoring of drug level and renal profile.
· Stress steroid dose should be provided in this lady.
· Surgery team should take in consideration midline incision safety in comparison to Pfannenstiel incision to avoid direct graft injury or ureteric complications especially with the presence of obstruction.
· Prophylactic antibiotics may be needed according to the multidisciplinary team decision.
Thank you
◇How do you manage her graft dysfunction?
______________________
This pregnant lady has an obstructive uropathy due to compression by the fetal head. (One of most common causes for obstructive uropathy is ureteral compression due to a gravid uterus [1]).
◇Management of this pt involve:
__________________________________
▪︎Percutaneous nephrostomy or ureteral stenting (this is considered for such a patient; however, both involve radiation exposure and hence ultrasound guidance has been used instead especially for percutaneous nephrostomy). Risks of procedure also involve ascending pyelonephritis, premature labor and sometimes ureteral perforation [2].
▪︎Repeated RFTs: If no improvement then search for other causes of acute rejection
▪︎Urine analysis to see if there is any evidence of infection.
▪︎Viral screening (CMV and BK)
▪︎ CNI trough level
◇Would you advise normal delivery?
____________________________
No, Although normal vaginal delivery without abdominal compression is the safest method of delivery in transplant patients [3]. Obstructive nephropathy is an indication of C/S in this patient [4].
◇If she requires CS, what are your precautions during the surgery?
______________________________
A multidisciplinary teams is needed with a consultant obstetrician, a transplant nephrologist, and also an expert staff of nurses and midwife are needed.
– Good informative past Medical history is indicated (for the transplant operation) and drug history).
_ Since both hypertension and hypotension are most likely to occur during cesarean delivery, circulation management can be difficult, and anesthesia should be managed so as to maintain sufficient renal perfusion and ensure postoperative renal function [5].
– Pre-operative planning with organ mapping and incision planning is imperative, with consideration for a vertical midline incision to avoid direct or shearing forces on the transplant kidney. Preoperative collaboration with the Transplant Surgery team is also important so they are available in case of emergency or need for intraoperative consultation[6].
________________________
Ref:
[1] V J Bañón Pérez et al. “Management of obstructive uropathy in pregnancy”. Actas Urol Esp. 1999 Mar.
[2] Obstructive nephropathy in a post-transplant pregnancy
Shobhana Nay
[3]Tülay Özlü, Melahat Emine Dönmez, etal “Safe vaginal delivery in a renal transplant recipient: A case report” https://dx.doi.org/10.5152/jtgga.2014.45389
[4] Badri Man Shrestha et al. “Injury to a transplanted kidney during caesarean section: a case report” Exp Clin Transplant. 2007 Jun.
[5] Shunsaku Goto, Risa Fukushima, and Makoto Ozaki ” Anesthesia management in 14 cases of cesarean delivery in renal transplant patients—a single-center retrospective observational study”.
https://dx.doi.org/10.1186/s40981-020-0317-z
[6] Catherine E. Gordon and Vasiliki Tatsis “Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature”.
Thank you
How do you manage her graft dysfunction?
1- obestetrician for possible manual manipulation of the fetus for changing the head position and also an early and safe delivery.
2- urologist for care of the PCN and possible uretric stenting.
3- nephrologist for follow-up of renal chemistry and treatment of even asymptomatic UTI
Would you advise normal delivery?
If she requires CS, what are your precautions during the surgery?
Thank you
-This is a case of AKI due to obstructive uropathy due to the pressure effect of fetal head (Gravid uterus) on the ureter.
-Other DDx include infection,stones, CNIs toxicity,graft rejection
-Urinary tract dilation is common during pregnancy due to hormonal effect especially during the second and third trimesters.
-I should relieve the obstruction first by percutaneous Nephrostomy under ultrasound guidance then ureteric stenting done which is effective way to relieve obstructive uropathy.
-additional measures include sending urinalysis and C/S to exclude infection.
-exclude BK nephropathy which is common cause of ureteral stenosis.
-exclude CMV infection
-exclude stone obstruction
-Tac level
-if the graft function not improved after these measures we should consider graft biopsy.
-For delivery I will advise to do normal vaginal delivery which is the preferred mode of delivery in transplant recipients unless there is strong obstetric indication for C.section .
-in this case I will chose C/S because there is already pressure effect on the graft kidney ureter by the gravid uterus.
-before operation the obstetrician should read the operative notes of the transplant surgery to be aware of the graft anatomy.
-midline vertical incision is preferred to avoid injury to the graft.
-multidisciplinary team must be available during delivery including the obstetrician,anasthetics, pediatrician, nephrologist and transplant surgeon
-steroid stress dose must be given before oberation if she is on steroids
-antibiotics prophylaxis must be given
-uretral stent inserted to guide the surgeon to avoid injury to it.
Very good
First of all , I will consult the gyn. and obs. ,if they can do any maneuver to change the position of fetus and release the obstruction.
If there is no way to manipulate then will resort to nephrostomy to relieve the obstruction.
I would recommend Cs for delivery ,if the normal vaginal delivery is unadvisable due to obstetric indications. There is already an obstructive nephropathy with compression of transplanted kidney ureter, however its not an absolute contraindication for normal vaginal delivery and would advise for a trial of vaginal delivery.
precautions during surgery:
1] kidney damage as it is lying in the course of Pfannenstiel incision line.
2] the risk of damage is more with repeated Cs due to adhesion.
3] Ureteric damage as its lying above the uterine artery.
4] Wound infection due to immunosuppresion.
5] Adrenal insufficiency secondary to corticosteroid use .
6]Multi disciplinary team involving transplant surgeon , urologist , transplant physician and gynaecologist is advisable
Multidisciplinary is wise
reference:
obstructive nephropathy in a post transplant pregnancy. Shobhana Nayak -Rao. SJKDT. 2016
This is a case of obstructive uropathy leading to acute kidney injury, ultrasound show hydroureter so the main line of management is percutaneous nephrostomy and uretral stenting which is the safe and more effective procedure in the treatment of allograft obstructive uropathy, prolonged uretral stent can give definitive treatment with low morbidity.
Additional lines of management are general urine analysis and culture and sensitivity, IS monitoring , trough level of CNI and also exclude other causes of AKI with frequent monitoring of graft function.
There is no contraindications of normal vaginal delivery in transplant recipient and it considered as the preferrable and safest way for delivery unless there other standard obsetrictical reasons for C/S .
Precautions before and during surgery first steroid dose should be adjusted with hydrocortisone vial 100mg, graft monitoring ,blood pressure monitoring and IS monitoring also presence of expert team during surgery.
References
_ Pappas P, Giannopoulos A, Stravodimos KG, et al. Obstructive uropathy in the transplanted kidney:definitive management with percutaneous nephrostomy and prolonged uretral stenting. Endourol[Internet]. 2001;15(7):719_23 Available from;
http://dx.doi.org/10.1089/08927790152596316
_ Danovitch GM. Handbook of kidney transplantation. 6th ed Philadelphia,PA:Lippincott Williams and Wilkans ; 2017.
Very good
How do you manage her graft dysfunction?
* Although pregnancy can cause hydronephrosis in native kidneys, renal transplant dysfunction during pregnancy due to obstruction is rare.
* Studay conducted that patients presented with deteriorating renal function and ultrasound showed transplant hydronephrosis with the graft compressed between the gravid uterus and liver, percutaneous nephrostomy was placed with improvement in graft function
The nephrostomy remained in situ for the rest of the pregnancy then removed postpartum with no recurrence of hydronephrosis and subsequent transplant biopsy showed no evidence of rejection. The gravid uterus may obstruct a transplanted kidney.(1)
# Would you advise normal delivery?
* Vaginal delivery is the preferred route of delivery and cesarean section is indicated only for obstetric indications.
*The renal allograft, which is located in the false pelvis, is not obstructive to the delivery of the fetus.
* Spontaneous labor can be allowed up to 38 to 40 weeks if there are no obstetrical complications.
*Stress dose steroids should be given to women during labor who are maintained on steroids for immunosuppression
##Pregnancy in renal transplant recipient is high risk and should be managed by a multidisciplinary team of high risk obstetrician, neonatologist, Transplant Surgeon and transplant nephrologist also close follow up with transplant nephrologist every 2 weeks during the prenatal care.(2)
# If she requires CS, what are your precautions during the surgery?
* caesarean section is performed mainly for obstetric reasons.
* Early discussions between the obstetrician and the transplant surgical team, are helpful in planning the surgical approach.
* stenting the ureter but before the surgery through the nephrostomy
* The muscles of the anterior abdominal wall overlying the transplanted kidney can adhere to the anterior surface of the kidney and this predisposes the kidney to injury while opening the abdomen or the uterus. This can be prevented by paying attention to the anatomic structures and through meticulous dissection.
*Keeping the bladder decompressed with a urethral catheter is important to reduce back pressure on the kidney and to prevent urine leak, as reflux of urine into the transplanted kidney is common.
* A surgical approach to the uterus during caesarean section through a midline incision, both on the abdominal wall and the uterus, as in a classic caesarean section, may be more appropriate in renal transplant recipients, particularly in patients with transplanted kidneys in both iliac fossae.
* Awareness of a possible injury of this nature while performing lower segment cesarean section in a renal transplant recipient is paramount, and a multidisciplinary approach should be adopted to avoid this complication, as it can pose significant risk to the survival of the transplanted kidney, the fetus, and the mother.(3)
References:
(1)P.B. Mark,I.V. McCrea,G. Baxter,M.A. McMillan Publication:
Transplantation Proceedings
Publisher: Elsevier
Date: November 2009
Copyright © 2009 Elsevier Inc. All rights reserved.
2) Murray J. E., Reid D. E., Harrison J. H., Merrill J. P.,et al. Successful pregnancies after human renal transplantation. The New England Journal of Medicine. 1963;269:341–343. doi: 10.1056/nejm196308152690704. [PubMed] [CrossRef] [Google Scholar]
(3)Rahamimov R, Ben-Haroush A, Wittenberg C, Mor E, Lustig S, Gafter U, et al. Pregnancy in renal transplant recipients: long-term effect on patient and graft survival. A single-center experience. Transplantation 2006; 81(5): 660-664
Very good
How do you manage her graft dysfunction?
-Urinary tract dilatation has been seen to occur quite frequently during pregnancy most often in the second and third trimester of pregnancy. Dilatation is more often right-sided but may occur bilaterally.
-Percutaneous nephrostomy under ultrasound guidance should be inserted to relieve the obstruction.
-urine analysis and for culture /sensitivity to rule out urinary tract infection
-Screening for BK virus(cause of ureteric stenosis).
-Tac level.
-If there is no improvement after relief obstruction: allograft biopsy.
Would you advise normal delivery?
– Vaginal delivery is the preferred route of delivery and cesarean section is indicated only for obstetric indications.
If she requires CS, what are your precautions during the surgery?
-A midline vertical C/S to avoid injury to the transplanted kidney.
– Obstetricians should :
-read the operative report from the transplant surgery to make themselves familiar with the anatomy, typically, the renal vessels are anastomosed to the iliac vessels, and the ureter is connected to the bladder from the iliac fossa
– perform transabdominal ultrasound at a minimum to localize the kidney prior to surgery, either formally or at bedside and can also consider MRI if ultrasound is limited or if better visualization is needed, such as assessing for abnormal placentation.
-Stress dose steroids should be given to the patient.
– Pregnancy in renal transplant recipients is high risk and should be managed by a multidisciplinary team of a high-risk obstetrician, neonatologist, transplant nephrologist, and surgeon.
References:
–Shobhana Nayak-Rao. Obstructive nephropathy in a post-transplant pregnancy. Year : 2016 | Volume : 27 | Issue : 6 | Page : 1290-1292
–Silvi Shah , and Prasoon Verma . Overview of Pregnancy in Renal Transplant Patients. Int J Nephrol. 2016; 2016: 4539342.
-Catherine E. Gordon & Vasiliki Tatsis .Shearing-force injury of a kidney transplant graft during cesarean section: a case report and review of the literature ,.BMC nephrologyArticle number: 94 (2019)
Good multidisciplinary approach.
kidney at the time of Cesarani section so surgeon should be more caution especially ureter and urinary bladder.
REFERENCE:
1-Mark P., McCrea I., Baxter G. and McMillan M. Hydronephrosis in a pregnant renal transplant patients. Transplant Proc, 2009; 41(9): 3962-3.
Good
1) The graft is susceptible to the normal physiological changes that occur during pregnancy, including ureteral dilatation and hydronephrosis. The graft ureter can be mechanically compressed by the gravid uterus while it expands. Mild to moderate hydronephrosis is developed in approximately two thirds of pregnancy after kidney transplantation in late stages of pregnancy. Impairment of graft function due to hydronephrosis is rare and mechanical obstruction should be considered in any patient who has severe hydronephrosis at any time during pregnancy or moderate dilatation in the first/second trimester. Percutaneous nephrostomy or ureteral stenting have been considered for these patients. In kidney graft dysfunction in the presence of hydronephrosis, concomitant acute rejection should be considered, although it’s occurrence in this setting is very rare because of the immunomodulatory effect of pregnancy.
For this patient, the presence of moderate hydronephrosis in the late second trimester in combination with deterioration in kidney function warrants decompression of kidney allograft by percutaneous nephrostomy or ureteral stenting. Nephrostomy and ureteral stent can be removed after delivery.
2, 3) In kidney transplant recipients, a trial of vaginal labor is advised, although they have a higher risk of cesarean delivery compared with the general population and it is nearly fivefold higher than in the general population (43 to 72 %). Deterioration of kidney function (about 16%) is one of the indications of cesarean delivery.
Vaginal birth is the preferred mode of delivery if there are no obstetric contraindications. Although most transplant patients (over 50 percent) will undergo a cesarean delivery, it should be reserved for obstetric indications only.
As the need for cesarean delivery for obstetric reasons is unpredictable, clinicians can perform an ultrasound in the third trimester to confirm the anatomic location of the graft in the setting of the gravid uterus.
If a cesarean delivery is planned, surgical support from the transplant team should be available in case of complication. Considering the anatomy and position of the transplanted kidney, the donor ureter, and the recipient’s bladder in relationship to the gravid uterus is crucial to avoid unintentional injury to these organs during cesarean section. Although injury to the allograft is uncommon with cesarean delivery, it has been reported following a horizontal incision.
In one study, there was no difference in short-term graft loss based on mode of delivery.
In this patient, making a decision to select delivery mode depends upon obstetrical indications and predelivery evaluation of an anatomic location of graft and ureter in relation to gravid uterus. If there is no obstetrical indication or surgical limitation, vaginal delivery can be a better option, but if it is not possible, cesarean delivery can be performed with the mentioned precautions.
Very good
this 24 weeks pregnant lady presented with AKI with one week earlier US relieving moderate hydroureter .
management plan:
1- Relive the obstruction with percutaneous nephrostomy.
2- Urine analysis , C &S to treat any current infection
3- Exclude other causes of AKI as
a- Exclude preeclapsia, GDM
b- Assess proteinuria level
c- Sepsis screen
d- CMV , BK PCR
e- CNI trough level
Would you advice normal delivery
Normal delivery is the safest delivery mode in transplant recipients unless CS is indicated for obstetric reason. for this lady , percutaneous nephrostomy should be followed up , changed every 4 weeks till delivery and try vaginal delivery if wasn’t CI at this time.
If CS is required :
1- Preoperative US to assess anatomy of the graft , its vascular supply and ureter position. Insert ureter stent to avoid its injury , midline insetion to avoid graft injury.
2- Consider stress dose steroid , if she was on high dose prednisolone
Decent succinct reply.
How do you manage her graft dysfunction?
This 25 year old pregnant lady had 3rd transplant with stable renal function on Tacrolimus and steroids. There is rise in creatinine from 70 micro mol to 115 micro mol. Imaging confirmed hydronephrosis. Patient had percutaneous nephrosotmy and a nephrostogram showing external compression in Ureter by fetal head. Dilatation of Pelvicalyceal system can be physiological during pregnancy but if there is rise in creatinine then obstruction should be ruled out. Whenever there is rise in creatinine, we have to make sure that there is no pre renal cause . The immunosuppressive drugs level and compliance has to be assessed and infections ruled out. In the absence of pre renal causes, Post renal causes like ureteric stricture and neoureterocystostomy site, stones , external compression, reflux nephropathy have to ruled out. The first step will be decompression by placing a PCN and see the creatinine trends. If there is no improvement then a biopsy is indicated
Would you advise normal delivery?
Vaginal delivery is the preferred method until there are obstetric indications. C Section off course will be a challenge as there is history of three previous transplants increasing the risk of adhesions, difficult anatomy and iatrogenic injuries.
If she requires CS, what are your precautions during the surgery?
This will require a multidisciplinary approach including Obstetric team, transplant team , Paediatrics and interventional radiologist. When planning a C section it will be better to place ante grade Ureteric JJ stent to identify Ureter and avoid injury . Pre operative patient counselling should be done thoroughly including the risks involved. The transplant surgeon should be around during C section.
Reference
Diane B Mckay. et al . Pregnancy after Kidney Transplantation. Clin J Am Soc Nephrol. 2008 Mar; 3(Suppl 2): S117–S125.
To your credit, you have ruled out common causes of AKI prior to offering percutaneous nephrostomy, you have also correctly emphasized that Transplant surgeons should be involved during peri delivery care.
How do you manage her graft dysfunction?
Although pregnancy can cause hydronephrosis in native kidneys, renal transplant dysfunction during pregnancy due to obstruction is rare. In this patient the graft dysfunction most properly due to mechanical obstruction by the foetal head , so percutaneous nephrostomy tube should be inserted to relieve the obstruction, followed by ureteral stenting.
Other causes of graft dysfunction showed be rule out and other causes of ureteric obstruction(BKV infection or stones ) showed be rule out.
Would you advise normal delivery?
Normal vaginal delivery unless there is an obstetric indication .
If she requires CS, what are your precautions during the surgery?
Special consideration showed be taken in this transplanted lady ,which include ;
1-The complex pelvic anatomy and its relation to the procedure ;
This include the transplanted pelvic kidney ,ureter and the bladder .
2- Intra operatively ensure well hydration
3- Stress dose steroid .
REFERENCE:
1-Mark P., McCrea I., Baxter G. and McMillan M. Hydronephrosis in a pregnant renal transplant patients. Transplant Proc, 2009; 41(9): 3962-3.
2- Shah, S., & Verma, P. (2016). Overview of Pregnancy in Renal Transplant Patients. International journal of nephrology, 2016, 4539342
Would you like to rule out rejection in this scenario? Does an increase in plasma volume during pregnancy play a role in this regard?
But leaving the above queries apart, you have mentioned all the salient points that are needed in a satisfactory answer.
This is a patient with 3rd renal transplant with excellent graft function at baseline, getting pregnant 3 years after transplant. She is on tacrolimus and steroids (no teratogenic drugs).
Moderate hydronephrosis can be present in normal pregnancy. But in the presence of a rise in creatinine with moderate hydronephrosis (and in absence of any pre-renal causes like hypovolemia), first and foremost thing to rule out is a mechanical obstruction.
Hence an ultrasound examination should be done and a guided percutaneous nephrostomy tube should be inserted to relieve the obstruction.
If there is no improvement with this, then we should look for other causes of graft dysfunction, including Tacrolimus drug levels, urine routine and culture examination to rule out urinary tract infection, BK virus PCR quantitative (cause of ureteric stenosis).(1,2) If still no clue, then a kidney biopsy would be required.
But in this case, it seems to be due to mechanical obstruction, hence percutaneous nephrostomy under antibiotic cover and antegrade DJ stent insertion through the nephrostomy tube later would be the best approach.(3)
In a pregnant transplant recipient, a normal vaginal delivery should be the first choice and caesarean section should be done only in presence of obstetric indications. Although, in this case, with 3 transplant kidneys, it might be difficult and caesarean section with a midline incision would be a better option.(4)
With multiple prior transplants, and features suggestive of mechanical obstruction, this case requires multidisciplinary involvement of the transplant surgeon, transplant nephrologist, obstetrician and urologist.
A prior ultrasound examination to assess the position of the transplanted kidneys and ureter as well as checking the operative notes of the transplant surgery with interaction with the transplant surgical team would help the obstetrician to get a complete picture.
The transplant team should also be present in the operation theater to help in case of any inadvertent graft injury.
A careful midline skin incision to approach the uterus (as there might be increased adhesions due to prior surgeries) should be used.
Antibiotic prophylaxis and stress dose steroids should be given.
During surgery, it is important to avoid hypotension. A prior knowledge of the anatomical location of the graft will help in avoiding it during the surgery.
References:
1) Yadav A, Salas MAP, Coscia L, Basu A, Rossi AP, Sawinski D, Shah S. Acute kidney injury during pregnancy in kidney transplant recipients. Clin Transplant. 2022 Apr 9:e14668. doi: 10.1111/ctr.14668. Epub ahead of print. PMID: 35396888.
2) Kumar S, Ameli-Renani S, Hakim A, Jeon JH, Shrivastava S, Patel U. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol. 2014 Dec;87(1044):20140169. doi: 10.1259/bjr.20140169. Epub 2014 Oct 6. PMID: 25284426; PMCID: PMC4243200.
3) Nayak-Rao S. Obstructive nephropathy in a post-transplant pregnancy. Saudi J Kidney Dis Transpl. 2016 Nov-Dec;27(6):1290-1292. doi: 10.4103/1319-2442.194698. PMID: 27900986.
4) Shrestha BM, Throssell D, McKane W, Raftery AT. Injury to a transplanted kidney during caesarean section: a case report. Exp Clin Transplant. 2007 Jun;5(1):618-20. PMID: 17617055.
Good.
How do you manage her graft dysfunction?
Physiological dilation of urinary tract occur frequently (~70%) during second & third trimester of pregnancy. This dilation can be because of increase in GFR, progesterone mediated relaxation of urinary tract & compression of ureter between fetal head & pelvic rim. The patent has graft dysfunction which is likely due to obstructive uropathy so percutaneous nephrostomy tube should be inserted to relieve the obstruction, followed by ureteral stenting with treatment of UTI if needed
Would you advise normal delivery?
Normal vaginal delivery is the preferred method, caesarian section is considered if there is any obstetric indications
If she requires CS, what are your precautions during the surgery?
Transplant team should be taken on board to take care of the anatomy and position of the transplanted kidney, the donor ureter, and the recipient’s bladder in relationship to the gravid uterus ,to avoid injury to these organs. And also to increase the dose of steroids during surgery.(stress dose)
REFERENCE:
1-Mark P., McCrea I., Baxter G. and McMillan M. Hydronephrosis in a pregnant renal transplant patients. Transplant Proc, 2009; 41(9): 3962-3.
2- Shah, S., & Verma, P. (2016). Overview of Pregnancy in Renal Transplant Patients. International journal of nephrology, 2016, 4539342
Good response
good afternoon
Ihave question regarding the best decompression in this case ,is it the antegrade PC nephrostogram and percutaneous nephrostomy with or with out antegrade DJ stenting or ureteroscopy approach ?
Percutaneous nephrostomy tube should be inserted to relieve the obstruction, ureteral stenting is considered to avoid recurrence of obstruction and to identify the ureter if caesarian section is needed
urine culture and treatment of UTI if present
Normal vaginal delivery is the preferred method, caesarian section is considered if there is obstetric indications
Multidisciplinary care
Ureteric stent to identify the ureter and avoid its injury
Stress dose steroids
Meticulous aseptic technique for cervical examination with attention to signs of chorioamnionitis in labor with prompt antibiotic treatment if needed
Careful wound closure and prophylactic antibiotics to avoid complications in immunocompromised patients
Careful fluid management.
Yadav A, Salas MA, Coscia L, Basu A, Rossi AP, Sawinski D, Shah S. Acute kidney injury during pregnancy in kidney transplant recipients. Clinical Transplantation. 2022 Apr 9:e14668.
Nayak-Rao S. Obstructive nephropathy in a post-transplant pregnancy. Saudi Journal of Kidney Diseases and Transplantation. 2016 Nov 1;27(6):1290.
del Mar Colon M, Hibbard JU. Obstetric considerations in the management of pregnancy in kidney transplant recipients. Advances in Chronic Kidney Disease. 2007 Apr 1;14(2):168-77.
Physiological dilation of urinary tract occur frequently (~70%) during second & third trimester of pregnancy. This dilation result of multiple factors ( increase in GFR, progesterone mediated relaxation of urinary tract & compression of ureter between fetal head & pelvic rim. Renal dysfunction is rare with physiological dilation.
This patient had graft dysfunction, so all causes of dysfunction should be excluded ( pre-renal, renal & post renal).
Dehydration should be corrected if present, screen for infection( e.g. CMV, BKV, UTI), screen for proteinuria, DSA.
Percutaneous nephrostogram show compression of ureter by fetal head( graft dysfunction caused by obstructive uropathy), so nephrostomy is advise to decompress the urinary tract with cover of antibiotic & monitoring of graft function & UOP. DJ can be placed if nephrostomy didn’t relieve obstruction & to prevent ureteric injury during CS ( if indicated).
NVD is preferred method for termination of pregnancy, but CS done when there is an obstetrical indication.
During CS, the patient need to increase the dose of steroid ( stress dose), & DJ to prevent ureteric injury.
References:
Management:
Base line serum creatinine before pregnancy is needed to evaluate possible changes of pregnancy on kidney function according to pregnancy stage.
Moderate to severe obstruction workup for AKI due to post-renal cause is indicated.
Obstruction could happen in the second or third trimester due to mechanical effect of the gravid uterus.
For hydro -nephrosis, percutaneous nephrostomy with US guidance can be deployed , a stenting can be considered if no response .Also, BK virus infection as a cause of ureteric obstruction need to ruled out.
Allograft biopsy if still no improvement to be considered.
Delivery:
Vaginal delivery is advised , CS is indicated according to obstetric indications.
Multidisciplinary team of obstetricians, neonatologists, and transplant nephrologists is required.
In case of CS, precautions include stenting the ureter to avoid injury, midline incision, if feasible& stress dose of steroids if indicated.
References:
Yadav A, Posadas Salas MA, Coscia L, Basu A, Rossi AP, Sawinski D, et al. Acute kidney injury during pregnancy in kidney transplant recipients.Clinical Transplantation. 2022;e14668.
Shah S, Verma P. Overview of Pregnancy in Renal Transplant Patients. International Journal of Nephrology. 2016.
Nayak-Rao Sh. Obstructive Nephropathy in a Post-transplant Pregnancy. SJKDT. 2016;27(6)
During normal pregnancy, glomerular filtration rate (GFR) increases by approximately 50 percent, and there is a reduction in serum creatinine levels. In pregnant transplant recipients, the decrease in creatinine may be more subtle.
Common causes of allograft dysfunction among pregnant recipients include
Rejection
Preeclampsia
volume depletion
CNI toxicity
obstruction
Infection
1- Once ureteric obstruction is confirmed or strongly suspected, urinary diversion must be undertaken to minimize kidney damage. This is best achieved by percutaneous nephrostomy insertion.
renal function will improved will be within 2–3 days ,followed by temporary antegrade ureteric stent placement
In Percutaneous nephrostomy insertion there is a risk of :-
*Bleeding
which should be minimized by ensuring an adequate platelet and haemoglobin count and coagulation time
a platelet count of >80,000 × 109 per litre, a haemoglobin of >8 g dl−1 and an international normalized ratio of <1.5 to be acceptable.
*UTI
Urine is tested for infection, and use of prophylactic antibiotics is directed by local policy.
-To exclude other causes of graft dysfunction we should monitor CNI levels every two to four weeks and maintaining them at the same levels as they were prior to pregnancy.
– If the patient suspected of having acute rejection, an ultrasound-guided kidney allograft biopsy should be performed to establish the diagnosis and guide treatment.
2- Vaginal birth is the preferred mode of delivery if there are no obstetric contraindications. Although most transplant patients (over 50 percent) will undergo a cesarean delivery, there is no clear evidence to support its routine use, and it should be reserved for obstetric indications only.
Vaginal birth should not be impaired, as the pelvic allograft does not obstruct the birth canal in most patients. The obstetrician should review operative notes from the transplant procedure to confirm location of the allograft and ureter. As the need for cesarean delivery for obstetric reasons is unpredictable, clinicians can perform an ultrasound in the third trimester to confirm the anatomic location of the graft in the setting of the gravid uterus.
This information should be placed in the prenatal record to guide the surgeon if a cesarean delivery is required. Prophylactic antibiotics are warranted to avoid complications in these immunocompromised patients so we need multidisciplinary team of obstetricians, pediatricians and transplant nephrologists.
3-If a cesarean delivery is planned
*surgical support from the transplant team should be available for the anatomy and position of the transplanted kidney, the donor ureter, and the recipient's bladder in relationship to the gravid uterus is critical to avoid unintentional injury to these organs. Injury to the allograft is uncommon with cesarean delivery but has been reported following a Pfannenstiel (ie, horizontal) incision
*Stress-dose steroids
In uncomplicated pregnancies, the use of stress-dose glucocorticoids is not routinely recommended for kidney transplant recipients who are taking chronic glucocorticoids with prednisone doses of 5 mg/day or less for maintenance immunosuppression.
We do administer stress-dose glucocorticoids in patients who are considered to be at high risk for adrenal insufficiency. Such patients include those who are experiencing a complicated pregnancy, are acutely ill, are hemodynamically unstable, and/or are likely to undergo surgery.
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Reference
1-Up to date
2-1S KUMAR, BSc (Hons), 2S AMELI-RENANI, MB BS, FRCR, 1A HAKIM, BSc (Hons), 1J H JEON, BSc (Hons), 3S SHRIVASTAVA, PhD, MRCP and 2U PATEL, MRCP, FRCR. Ureteral obstruction following renal transplantation: causes, diagnosis and management. Br J Radiol;87:20140169.
Thank you, Dr. Dalia, for bringing the differential diagnosis of graft dysfunction
Even in the native kidneys, hydronephrosis should be relieved by the stent. hydronephrosis in one side is expected to affect the contralateral side due to a change in hydrostatic pressure affecting eGFR. Here as we have only one kidney, this is more important. A double J stent or nephrostomy should be placed to relieve intraglomerular pressure. Here postrenal component seems to be the primary cause. If so, the creatinine will drop to normal within a couple of days. prolonged hydronephrosis may have irreversible effects..
Normal delivery is possible. C/S is not mandatory unless indicated otherwise