This study is systematic review with level 1 of evidence. Patients with ESKD have impairment in reproductive system and fertility, with low incidence of conception (0.9-7%), because of disturbance in hypothalamic-gonadal axis. Kidney transplantation leads to improvement in reproductive function, but pregnancy in kidney transplant recipients is associated with some adverse clinical outcomes. Pregnancy in kidney transplant recipients is correlated with risk of adverse maternal complications of preeclampsia and hypertension, and risk of adverse fetal outcomes of premature birth, low birth weight, and small for gestational age infants. In addition, increased risk of side effects from immunosuppressive medication, and risk of deterioration of allograft function are reported. In this systematic review 1343 studies are evaluated and finally 87 met inclusion criteria. Different factors were evaluated in this systematic review. Pregnancy outcomes consist of Live birth rate was 72.9%, miscarriages rate was 15.4%, induced abortions rate was 12.4%, stillbirths rate was 5.1% and rate of ectopic pregnancies was 2.4%. In terms of maternal outcomes, Overall, rates of preeclampsia was 21.5%, cesarean section was 62.6%, gestational diabetes was 5.7%, and pregnancy induced hypertension was 24.1%. Fetal outcomes including Overall, rate of preterm birth was 43.1%, and neonatal mortality was 3.8%. The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%. creatine level changes significantly post pregnancy, compared to pre conception. Time of conception 2-3 years post-transplant was associated with higher abortion rate, neonatal death, and cesarean section rate. Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3-year interval after transplantation. Lower birth weight rates, and preeclampsia rates were higher in women in older age range. Both maternal and fetal adverse events are common in post-transplant pregnancies. Rates of preeclampsia, still birth, rates of preterm delivery, cesarean section, and neonatal mortality were significantly higher than in the general population. The rates of preeclampsia were almost six-fold higher as compared to the general population. Several factors can relate to the onset of hypertension after renal transplantation, consist of the type of immunosuppressive therapy (calcineurin inhibitors and corticosteroids), allograft function, donor type, obesity, alcohol, smoking, and presence of a native kidney (increased production of renin). As a result of higher frequency of preexisting hypertension and proteinuria, diagnosis of superimposed preeclampsia can be difficult in kidney transplant patients. The rate of gestational diabetes is also higher in kidney transplanted pregnant women possibly due to immunosuppressive medications like steroids and calcineurin inhibitors. Cesarean section was two-fold of general population. Although vaginal delivery should not be impaired in kidney transplant patients, as the pelvic allograft does not obstruct the birth canal in most patients, exceptionally higher rates of cesarean sections in kidney transplant recipients can be related to fetal and maternal complications. The ideal time of conception in women with renal transplant is suggested between 1 and 2 years after transplantation.
Alshymaa Eltahan
2 years ago
This study is a meta-analysis study, level 1 evidence. A higher incidence of some medical complications in pregnant transplanted females has been reported compared to non-transplant pregnancies, as follow:2
A. Pre-eclampsia incidence is 24-36% compared to 4-5%.
B. Gestational diabetes incidence is 8% compared to 3.9%.
C. Urinary tract infections (UTI) incidence is 14.6- 42% compared to 7%.
D. C-section > 50%, mostly due to obstetric indications.
Regarding the fetal outcomes:2
A.Higher rates of pre-term delivery (40-50%); risk increases with maternal hypertension and serum creatinine > 1.7 mg/dl.
B. Higher incidence of fetal growth retardation (FGR); risk increases with maternal hypertension, proteinuria, and CNI use.
C. Increased incidence of low birth weight.
D. Spontaneous abortion is comparable to the general population with an incidence of 13-26 %; increased risk with MMf exposure.
E. Increased incidence of stillbirth compared to the non-transplant population.
However, sensitized patients could have a higher risk incidence 7.
Nasrin Esfandiar
2 years ago
This article is a systemic review and meta-analysis and provides level 1 of the evidence.
To determine outcome of pregnancy in kidney transplant recipients and its maternal and fetal complication, 87 studies with 6712 pregnancies in 4174 KT recipients were included.
Studied outcomes were as following:
1- Live birth rates higher compared to the US general population (72.9 % vs 62%)
2- Slightly lower rate of miscarriage (15.4 % vs general population but higher than Africa and south America.
3- Still birth rate was higher was higher than general population (5.1%vs 0.6%)
4- Slightly higher rate of ectopic pregnancy. (2.4% vs 1.4%)
5- Abortion rate was lower than the US general population (12.4%VS 1.4%)
6- Ectopic pregnancy was slightly higher than the US general population (2.4% vs 1.4%)
7- Preeclampsia was higher among kidney TX recipients (21.5%) than general population.
8- Rate of cesarean section among kidney recipients was 62.5 %(higher than general population).
9- Gestational diabetes among kidney TX recipients was 5-7 % which was lower than general population.
10- Pregnancy induced hypertension among kidney transplants recipients was 24.1 %
11- Preterm birth among kidney TX recipients was higher than general population (43.2%)
12- Neonatal mortality was higher than general population (3.8%)especially in Africa.
13- The acute rejection rate during pregnancy was 9.4% which was not different from the US mean of 9.1 %
14- The change in creatinine pre. and post pregnancy was statistically significant (1.23 VS 1.37)
15- The outcome considering neonatal deaths, C/S and live birth rate were less favorable in the patients who became pregnant in the interval of 2-3 years
Comparing with the > 3year, and < 2year interval (73% vs 65% vs 42%)
So, both maternal and fetal complication are common is kidney TX recipient s but totally favorable outcome especially regarding live birth rates were seen with preservation of the graft.
Dalia Eltahir
2 years ago
level of evidence: I ( a systematic review , metanalysis }
ESRD patients mainly have infertility and sexual problems ,this may be multi-factorial due to chronic inflammation ,uremia , medications, and hormonal factors . Post transplantation fertility and sexual desire improved .Complication occur in transplant patients during pregnancy ; spontaneous abortion in 15% stillbirths in 5 %, ectopic pregnancies in 2.4%, pre eclamptic toxemia in 21%, gestational diabetes in 5.7%, pregnancy induced hypertension in 24%, increased rate of elective cesarean section in 62% and preterm delivery in 43% . No need for elective C S because the graft does not causing any obstruction during normal labour .
fetal outcomes in renal transplant recipient are premature birth 43.1 % low birth weight, and small for gestational age infants.American guidelines recommended pregnancy after 1year post stable graft function {serum creatinine <1.5 mg/dl,and proteinuria <500 mg/24 h } while European guidelines recommend two year after kidney transplant .After 1year suitable graft function and there is no episode of rejection after discussion with nephrologist and counseling recipient about risk of pregnancy on graft function ,immunosuppression medication should be review . Pregnancy and outcome of the graft : Increase rate of acute rejection by ( 9.4 %) , and increase graft loss in the following 2 years (9.2 % ).
Assafi Mohammed
2 years ago
This is meta-analysis, observational study. Equivalent to level 1a.
Outcome presented by this study
Pregnancy outcome:
· Live birth rate 72.9%
· miscarriages rate 15.4%
· induced abortions rate 12.4%: lower than the US general population
· stillbirths rate 5.1%
· rate of ectopic pregnancies 2.4%: higher than the general population.
In this study cohort of kidney transplant recipients, live birth rates were higher and favorable across all geographic regions as compared to the US general population. Miscarriage rate was slightly lower than that of the US general population but higher in Africa and south America, while the rate of stillbirth is higher than the general population in USA, Asia and Africa.
Maternal outcomes
· rates of preeclampsia 21.5%
· cesarean section rate 62.6%
· rate of gestational diabetes 5.7%
· rate of pregnancy induced hypertension 24.1% Fetal outcomes
· rate of pre-term birth 43.1%
· neonatal mortality was 3.8%
· The mean gestational age for newborns was 34.9weeks
· the mean birth weight was 2470 g (US mean, 3389 g).
Graft outcomes
· Acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% which was comparable to the US mean of 9.1%.
· Rate of graft loss was 9.2% among 489 recipients in 12 studies.
Mohamed Ghanem
2 years ago
The level of evidence is I as its meta-analysis
Summary: Pregnancy outcomes :
The live birth rate was 72.9%, abortions was 15.4%,stillbirth rate was 5.1% and ectopic pregnancy was 2.4 % . Women outcomes : increase rate of pre-eclampsia (21.5 % ) ,gestations DM (5.1 % ),pregnancy-induced Hypertension (24 % )and increase rate of CS . Fetal outcomes:
Increase rate of preterm birth (43.1%) , low birth weights, and increase neonatal mortality. Graft outcomes :
Increase rate of acute rejection ( 9.4 %) , an increase in creatinine level post-pregnancy in comparison to pre-pregnancy, and increase graft loss in the following 2 years (9.2 % ).
mai shawky
2 years ago
Level of evidence: I (as it is a systematic review and metanalysis)
Summary
Most of ESRD patients are infertile. However, recovery of hypothalamo-pit-gonadal axis was reported early after successful kidney transplantation in both males and females.
Pregnancy in kidney transplant recipients can be complicated by many issues as spontaneous abortion in 15%, induced abortions in 12 %, stillbirths in 5 %, ectopic pregnancies in 2.4%, pre eclamptic toxemia in 21%, gestational diabetes in 5.7%, pregnancy induced hypertension in 24%, increased rate of elective cesarean section in 62% and preterm delivery in 43% (1).
Hypertension is a common complication and was attributed to effect of steroids, CNI, original kidney disease and other personal factors as obesity and alcohol consumption. Gestational diabetes mostly related to steroid. CNI use in addition to ethnic and genetic predisposition to diabetes.
Increased rate of elective cesarean section should be discouraged as pelvic allograft does not obstruct the natural delivery through the birth canal (2, 3).
Hemolytic uremic syndrome (HUS), intrahepatic cholestasis, maternal hemorrhage and urinary obstruction were also documented in pregnancy after KT. Preeclampsia is defined as maternal hypertension and proteinuria combined with placental insufficiency and intra uterine growth retardation (4-7). it is a leading cause of fetal, early neonatal deaths and graft loss (8).
Poor fetal outcomes include premature birth (9, 10), low birth weight, and small for gestational age infants (2).
American Society of Transplantation recommends to delay conception for at least one-year post transplantation, whereas European best practice guidelines recommend at least 2 years to optimize the pregnancy and graft outcomes (11, 12). Such delay in pregnancy is a major problem especially in old mothers as age more than 35 years, with decreased ovarian reserve, will have lower fertility which represents a major psychological and relationship stress (13). psychological assessment and assurance plays a pivotal role in management of infertility in transplant recipients (14).
Pregnancy with pre-conception GFR of less than 40 ml/min/1.72 m2 was associated with poor graft and fetal outcomes (15). The graft loss may be attributed to hyper-filtration injury and progressive proteinuria (16, 17). Higher preconception GFR allows pregnancy to come to term and improve the neonatal outcomes (15).
References:
1. Shah S, Venkatesan RL, Gupta A, Sanghavi MK, Welge J, Johansen R, et al. Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review. 2019;20(1):1-22.
2. Bramham K, Nelson-Piercy C, Gao H, Pierce M, Bush N, Spark P, et al. Pregnancy in renal transplant recipients: a UK national cohort study. 2013;8(2):290-8.
3. Shah S, Verma PJIjon. Overview of pregnancy in renal transplant patients. 2016;2016.
4. Steegers EA, Von Dadelszen P, Duvekot JJ, Pijnenborg RJTL. Pre-eclampsia. 2010;376(9741):631-44.
5. Lisonkova S, Joseph KJAjoo, gynecology. Incidence of preeclampsia: risk factors and outcomes associated with early-versus late-onset disease. 2013;209(6):544. e1-. e12.
6. Mol BW, Roberts CT, Thangaratinam S, Magee LA, De Groot CJ, Hofmeyr GJJTL. Pre-eclampsia. 2016;387(10022):999-1011.
7. Wiles K, Chappell LC, Lightstone L, Bramham KJCJotASoN. Updates in Diagnosis and Management of Preeclampsia in Women with CKD. 2020;15(9):1371-80.
8. Majak GB, Sandven I, Lorentzen B, Vangen S, Reisæter AV, Henriksen T, et al. Pregnancy outcomes following maternal kidney transplantation: a national cohort study. 2016;95(10):1153-61.
9. Deshpande N, James N, Kucirka L, Boyarsky B, Garonzik‐Wang J, Montgomery R, et al. Pregnancy outcomes in kidney transplant recipients: a systematic review and meta‐analysis. 2011;11(11):2388-404.
10. Mohammadi F, Borg M, Gulyani A, McDonald S, Jesudason SJCt. Pregnancy outcomes and impact of pregnancy on graft function in women after kidney transplantation. 2017;31(10):e13089.
11. EBPG Expert Group on Renal Transplantation %J Nephrology D, Transplantation: Official Publication of the European Dialysis, Association TA-ER. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV. 10. Pregnancy in renal transplant recipients. 2002;17:50-5.
12. McKay DB, Josephson MAJAjot. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. 2005;5(7):1592-9.
13. Szymusik I, Warzecha D, Wielgoś M, Pietrzak BJAot. Infertility in Female and Male Solid Organ Recipients–From Diagnosis to Treatment: An Up-To-Date Review of the Literature. 2020;25:e923592-1.
14. Olbrisch ME, Benedict SM, Ashe K, Levenson JLJJoc, psychology c. Psychological assessment and care of organ transplant patients. 2002;70(3):771.
15. Schwarz A, Schmitt R, Einecke G, Keller F, Bode U, Haller H, et al. Graft function and pregnancy outcomes after kidney transplantation. 2022;23(1):1-11.
16. Sun K, Lin D, Feng Q, Li F, Qi Y, Huang C, et al. Parity is associated with albuminuria and chronic kidney disease: a population-based study. 2019;11(23):11030.
17. Park S, Lee SM, Park JS, Hong J-S, Chin HJ, Na KY, et al. Midterm eGFR and adverse pregnancy outcomes: the clinical significance of gestational hyperfiltration. 2017;12(7):1048-56.
Naglaa Abdalla
2 years ago
This is level 3 evidence.
Pregnancy is rare in dialysis women due to affected hypothalamic gonadal axis with conception rate from 0.9 to 7%.
After transplantation the fertility will improved within 6 months in some cases but conception is not without risk to the mother and the fetus.
Here is a meta analyses report according to PRISMA guidelines for studies explaining incidence and outcomes of pregnancy in kidney transplanted women.
1343 unique studies, 87 met inclusion criteria, representing 6712 pregnancies in 4173 kidney transplant recipients.
The mean maternal age was 29.6 – 24 years.
Pregnancy outcomes:
Live birth rate was 72.9%
Miscarriage 15.4%
Induced abortion 12.4%
Still birth 5.1%
Ectopic pregnancies 2.4%
Maternal outcomes:
Preeclampsia 21.5%
Cesarean section 62.6%
Pregnancy induced hypertension 24.1%
Fetal outcomes:
Preterm birth 43.1%
Neonatal mortality 3.8%
Graft outcomes:
Acute rejection 9.4%
Time of conception:
It was found that more adverse effect to the mother and the fetus in 2 – 3 years following transplantation as compared to 3 years.
In conclusion this meta-analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients.
Data was collected over several decades all over the world showing favorable outcomes in live birth rates higher than normal population but high risk of maternal and fetal adverse effect that signify proper counseling and planning.
Abdullah Raoof
2 years ago
.
1- What is the level of evidence of this study?
This study is a meta analysis – level 1 .
2- Summarise the pregnancy outcome presented by this study
Introduction
Women with ESRD get infertility due to defect of hypothalamic gonadal axis.Gestation is rare in women on dialysis ( 0.9 to 7%).
Kidney transplantation provide best chance for pregnancy as fertility is restored within 6 month post transplantation .
Inspite of this Pregnancy in a kidney transplant recipient continues has it own fetal and maternal complication such as
1. preeclampsia
2. hypertension,
3. premature birth,
4. low birth weight,
5. small for gestational age infants
6. side effects from immunosuppressive medication,
7. Risk of deterioration of allograft function .
Therefore, preconception counseling , family planning and contraception are pertinent parts of the transplant counseling process.
Pregnancy outcome :
. Rates of preeclampsia, still birth, and cesarean section were significantly higher than in the general population.
In one study , a quarter of women had serious pregnancy complications .and the rates of preterm delivery, still births, and neonatal mortality were higher as compared with the US recent national data.
The live birth rates in women after kidney transplant were higher than in the general population (73% vs. 62%) .
In contrast to these findings of successful pregnancies, in one a US study found a much lower live birth rate of 55% in kidney transplant recipients.
This study demonstrate the high maternal and fetal complications in women with kidney transplants. About one fourth of women developed preeclampsia, and the rates of preeclampsia were six times higher as compared to the general US population.
In a study by Vannevel et al. showed a preeclampsia rate of as high as 38%, and chronic hypertension rate of 27% .
The stillbirth and neonatal mortality rate were higher in this study as compared to the general
population.
This study, the cesarean section rate was two times higher as compared to general population in United States . Vaginal deliveryshould not be neglected in transplant women , as the pelvic allograft does not obstruct the birth canal in most patients .
The best time to pregnancy after transplantation remains grey zone.
American Society of Transplantation recommend the ideal time on pregnancy of 1-2 years after transplantation , while European best practice guidelines recommend a gestation after 2 year from transplantation.
In this study, live birth rate was lowest and neonatal deaths were highest in the 2–3 year interval following kidney transplant.
Maternal complication of cesarean section and preeclampsia were higher in the 2–3 and>3year interval. Contrary to this finding , Deshpande et al. reported both the highest maternal complications of preeclampsia, cesarean section, and gestational diabetes, and least favorable delivery outcome of preterm births in the < 2 year interval as compared to > 2 year interval between kidney transplant and pregnancy.
CARLOS TADEU LEONIDIO
2 years ago
What is the level of evidence of this study?
This is a secundar study. Metaanalysis and systematic review are level 1.
Summarise the pregnancy outcome presented by this study
The pregnancy outcomes included:
– Number of live births: Live birth rate was 72.9% (95% CI, 70.0–75.6). It was higher as compared to the US general population (72.9% vs. 62%) and favorable across all geographic regions. There are inconsistencies in definition of live birth rate used in various studies, but It´s possible that what is more important is that the numbers may reflect a reporting bias or a selection bias in which relatively healthy women decided to pursue pregnancy, and subsequently received better medical support by multiple specialties.
– Miscarriage: rate was 15.4% (95% CI, 13.8–17.2). It was slightly lower than that of the US general population (15.4% vs. 17.1%), but higher across Africa (21.0%), and South America (20.2%);
– Induced abortion: rate was 12.4% (95% CI, 10.4–14.7). It was also lower than the US general population (12.4% vs. 18.6%), was highest in South America (19.8%), followed by Asia (13.3%;), Oceania (11.5%;), North America (10.9%;), Europe (10.0%; ), and Africa (7.7%)
– Still birth: rate was 5.1% (95% CI, 4.0–6.5) . It was higher than the US general population (5.1% vs. 0.6%). Worldwide, stillbirth rate was highest in Asia (6.6%), and lowest in Africa (2.6%)
-Ectopic pregnancies: rate of ectopic pregnancies was 2.4% (95% CI, 1.5–3.7). It was slightly higher than the US general population (2.4% vs. 1.4%), with highest rate in Asia (3.3%)
Ofonime Udoh
2 years ago
A] What is the level of evidence of this study?
The level of evidence of this Study is Level 1
B] Summarise the pregnancy outcome presented by this study
Repoductive function, which is poor in patients with End Stage Renal Disease [ESRD] improve after renal transplant, but the pregnancy is associated with may advere risk factors.This study is a meta analysis that looked at 87 studies, representing 6712 pregnancies in 4174 kidney transplant recipients.
The mean maternal age was 29.6+/-2.4 years; live birth rate was 72.95.
Pregnancy outcome: live birth rates were higher than US population and favorablr across all the geographic region studied. Compared to the general population the rates of miscarraige and abortions was lower.
Matern;l putcomes: there was a higher rate of Pregnancy induced hypertension,preecclmapsia and Ceaserean section in those with renal transplant when compared to the US mean. Gestational diabetes rates were lower
Fetal outcomes: The mean Geatational age fpr new borns was 34.9 weeks compared to 38.7 weeks in the US. The mean birth weight was 2470g compared to 3389g in the US. The overall rate of preterm birth was high, and neonatal mortality rate was also high, neonatal mortality being high acro all geographical regions compared to the US mean
Graft outcome: The overall acute rejection rate was 9.4%n and this was comparable to the US mean of acute rejection in non-pregnant transplant recipients.
Times of Conception: Induced abortion and neonatal deat rates were highest in the 2-3 year interval following time of transplant as compared to rates at >3 years post tranplant and < 2 years post transplant. Caeserean secion rates and live bniurth rates also folowed this pattern: were leess favorable during the 2-3 year post transplant period.
Maternal age for conception: there were lowerlive birth rates in women aged 29-34 years compared to those aged <29 years. Rates of spontaneous abortion were the highest in women aged <25 and >35; precclampsia rates wrere hignherst in tjose aged >35 and lowest in those <25 years.
This study had a high rate of live births, compared to another study that had lower live birth rates, especailly as it also included fetal loses. It is estimated that about 40% of conceptions in females who have had a renal transplant do not go beyond the first trimester; but those thst do go past this trimester usually result in a live birth.
AMAL Anan
2 years ago
Summarise the pregnancy outcome presented by this study
The incidence of pregnancy in women on dialysis is low 0.9-7% due to disruption in hypothalamic gonadal axis, however fertility post transplantation restore within 6 months * the occurrence of adverse maternal complication , pre-eclampsia , hypertension feral complication ( low birthweight, small forgestional birth weight) cha make pregnancy
Challenge for transplant recipient.
So family planning considered important corner in transplantation program.
* this meta- analysis shown as below:-
– induced abortion rate less than us general population( 5.1, 0.6%) respectively.
– miscarriage is little lower than us general population ( 15.4, 17.1% ) respectively.
– live birth higher than us general population( 5.1, 0.6% ) respectively
– pre-eclampsia 12.4%
– gestational dm 5.7%.
– neonatal mortality 3.8%
Conclusions…
pregnancies in 4174 kidney transplant recipients with data spread over different decades from all over the world shows favorable outcomes with live birth rates exceeding that in the recent national population. Majority of patients preserve their graft. However,
pregnancy after renal transplant confers significant risk in terms of maternal and fetal adverse events, in- cluding increased rates of preeclampsia, gestational diabetes, cesarean section rates, and pregnancy in- duced hypertension. The risk of prematurity and low birth rate are also high. Areas which need to be studied in the future include type of immunosuppression and its cor- relation with specific pregnancy outcomes; and evaluation of risk factors associated with specific maternal and fetal adverse events. The definitions used in evaluating these outcomes also need to be standardized. The results of this study can help the health care providers with appropriate counseling and individualized management of this high risk population.
References
1. Shah S, Verma P. Overview of pregnancy in renal transplant patients. International journal of nephrology. 2016;2016:4539342.
2. Saha MT, Saha HH, Niskanen LK, Salmela KT, Pasternack AI. Time course of serum prolactin and sex hormones following successful renal transplantation. Nephron. 2002;92(3):735–7.
3. Bramham K, Nelson-Piercy C, Gao H, Pierce M, Bush N, Spark P, Brocklehurst P, Kurinczuk JJ, Knight M. Pregnancy in renal transplant recipients: a UK national cohort study. Clin J Am Soc Nephrol : CJASN. 2013;8(2):290–8.
4. Sifontis NM, Coscia LA, Constantinescu S, Lavelanet AF, Moritz MJ, Armenti VT. Pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolate mofetil or sirolimus. Transplantation. 2006;82(12):1698–702.
5. Davison JM, Redman CW. Pregnancy post-transplant: the establishment of a UK registry. Br J Obstet Gynaecol. 1997;104(10):1106–7.
AMAL Anan
2 years ago
What is the level of evidence of this study?
Level of evidence I
MICHAEL Farag
2 years ago
Level of the evidence is level I Maternal outcomes
rates of : – preeclampsia was 21.5%
– cesarean section was 62.6%
– gestational diabetes was 5.7%
– pregnancy induced hypertension was 24.1%
Fetal outcomes
– preterm birth (babies born alive before 37 weeks of gestation) was 43.1%
– neonatal mortality was 3.8%
Graft outcomes
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%.
The time of conception is an important determinant of the outcome
Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to < 2 year interval and > 3 year interval (16% vs. 11% vs. 10, and 9% vs. 3% vs. 4% respectively).
Maternal age for conception has an impact on the outcomes:
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs.76%). Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
Tahani Hadi
2 years ago
It is meta analysis study with level I evidence.
In this study we can conclude that kidney transplantation carries higher risk for both fetal and maternal side effects such as higher rate of preeclampsia,gestational diabetes and hypertension,cesarean section rate and other complications all are significantly higher in kidney recipient women compared to normal population.
Pregnancy outcomes
– live birth has a higher rate compared to US and it’s rate was 72.9% and miscarriage rate is lower than US with a rate of 15.7%
– ectopic pregnancy rate was 2.4% while still birth rate was 5.1%
– induced abortion rate was 12.4%
Maternal outcomes:-
-Pre eclampsia rate was 21.5%
-cesarean section rate was 62.6%
-gestetional diabetes was 5.7%
-pregnancy induced hypertension was 24.1%
Fetal outcomes
– preterm birth was 43.1%
– neonatal mortality was 3.8%
Graft outcome
– overall acute rejection in pregnant women having kidney transplant during pregnancy was 9.4% while graft loss post pregnancy by years was 9.2 %
kumar avijeet
2 years ago
This meta-analysis included a total of 87 studies, involving 6712 pregnancies in 4127 kidney transplant recipients. The pregnancy outcomes are as follows:
1) Higher rates of live births than the general population, with half of them having preterm delivery. Women in the age group 29-34 years showed lower live birth rates.
2) 25 % pts have stillbirths and ectopic pregnancies than the general population.
3) Lower rates of miscarriages and induced abortions seen in transplant recipients.
4) Rates of preeclampsia were 6 times higher than the general population
5) Rates of Cesarean sections were 2 times the general population.
6) Gestational diabetes mellitus was less common in the transplant recipients.
7) Pregnancy induced hypertension was seen in one fourth of the transplant recipients.
8) Approximately 10 times higher neonatal mortality was seen in the transplant recipients.
9) Among the transplant recipients. the mean birth weight was less than 2500 grams and mean gestational age for newborns was 34.9 weeks.
10) Acute rejection rates were comparable to the non-pregnant transplant recipients.
11) Time of conception decides about pregnancy outcomes with lowest live birth rates and highest neonatal deaths seen among pregnancies in 2-3 year interval post-transplant.
12) Fetal outcomes were better in pregnancies within 2 years post-transplant, but could be a manifestation of reporting bias.
Overall, the rates of maternal and fetal complications were higher in the transplant recipients, but having a better outcome than general population with preservation of graft function.
Level 1 evidence
Theepa Mariamutu
2 years ago
WHAT IS THE LEVEL OF EVIDENCE OF THIS STUDY?
level I
SUMMARISE THE PREGNANCY OUTCOME PRESENTED BY THIS STUDY
women who undergoing dialysis found to have low incidence of conception (0.9 to 7%), due to disruption of the hypothalamic gonadal axis. Transplantation considered the best way for women who undergoing dialysis wished to become pregnant. Pregnancy in a KTR is challenging due to:
Maternal complications (preeclampsia, hypertension, and gestational diabetes)
Foetal outcomes (premature birth, low birth weight, small for gestational age infants, and side effects from immunosuppressive medication).
Deterioration of allograft function.
Preconception counselling, family planning, and contraception are pertinent parts of the transplant counselling
The primary objective of this study was to perform a meta-analysis to systematically identify all studies of pregnancy-related outcomes in kidney transplant recipients around the world and estimate pooled incidence of pregnancy outcomes, maternal complications, and foetal complications. The secondary outcome was to examine the impact of pregnancy on the kidney allograft loss, and allograft rejection, identify the ideal maternal age of conception and determine the ideal time of conception between kidney transplant and pregnancy
The study demonstrated
Live birth rates were higher as compared to the US general population (72.9% vs. 62%).
Miscarriage rate was slightly lower than US general population (15.4% vs. 17.1%)
Induced abortion rate was also lower than the US general population (12.4% vs. 18.6%).
Stillbirth rate was higher than the US general population (5.1% vs. 0.6%).
The rate of ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%).
Preeclampsia was 21.5%( US mean, 3.8%),
Caesarean section was 62.6% (US mean, 31.9%).
Gestational diabetes was 5.7% (US mean, 9.2%),
Pregnancy-induced hypertension was 24.1%
Foetal outcomes
Preterm birth was 43.1%
Neonatal mortality was 3.8%
Rates of preterm birth were highest in South America (55.0%), and lowest in North America (35.4%).
The mean gestational age for new-born was 34.9 weeks
mean birth weight was 2470 g
Neonatal mortality was high across all geographical regions (3.8% vs. 0.4%).
Graft outcomes
The overall acute rejection rate during pregnancy was 9.4% vs 9.1%
Two-year post-pregnancy graft function was reported, and there were 32 cases of graft loss (9.2%). The change in preconception creatinine and post-pregnancy creatinine, was statistically significant (1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007).
Asmaa Khudhur
2 years ago
Level of evidence I
Pregnancy outcomes
live birth rates were higher as compared to the US general population
miscarriage rate was slightly lower than that of the US general population
Induced abortion rate was also lower than the US general population
stillbirth rate was higher than the US general population
The rate of ectopic pregnancy was slightly higher than the US general population
Maternal outcomes:
rates of preeclampsia was 21.5%
cesarean section was 62.6%
gestational diabetes was 5.7%
pregnancy induced hypertension was 24.1%
Fetal outcomes
rate of preterm birth was 43.1%
neonatal mortality was 3.8%
The mean gestational age for newborns was 34.9weeks
the mean birth weight was 2470 g
Neonatal mortality was high across all geographical regions as compared to the US mean
Graft outcomes
The overall acute rejection rate during pregnancy was 9.4%
With regards to graft failure, there was large variability in the follow up period ranging from 1 year to 14 years. However among 489 recipients in 12 studies where two-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%)
Time of conception
Outcomes were stratified by interval of 3 years between pregnancy and kidney transplant
Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3year interval following kidney transplant as compared to 3 year interval .Cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years than > 3 year, and 3 year
interval than 3 years interval followed by 2-3 years interval, and <2 years interval.
Maternal age for conception
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years .Rates of spontaneous abortion were highest in women 35 years followed by women with maternal age 25–34years .Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
Wee Leng Gan
2 years ago
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review
This is a systemic review and meta analysis on the pregnancy outcome in women with renal transplant with level 1 evidence. This review study the associations of maternal age, the interval between kidney transplant, and the pregnancy outcomes. Subgroup analysis included maternal and fetal outcomes for studies published from 2000 to 2017. There were 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years. For the pregnancy outcomes Live birth rate was 72.9% miscarriages rate was 15.4% , induced abortions rate was 12.4% , stillbirths rate was 5.1% and rate of ectopic pregnancies was 2.4% . For maternal outcomes, the rates of preeclampsia was 21.5%, cesarean section was 62.6%, gestational diabetes was 5.7%, and pregnancy induced hypertension was 24.1%. For fetal outcomes, the rate of preterm birth was 43.1% and neonatal mortality was 3.8%. For graft outcomes, acute renal allograft rejection were highest in Asia (11.0%), followed by South America (10.7%), Oceania (9.1%), Europe (7.3%), North America(6.7%), and Africa (4.8%). Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant, cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years. On the other hand, maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year (24% vs. 23% ). Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and<2 interval (16% vs. 14% vs. 10%).Lower live birth rate was observed in women with maternal age 29–34 years. Rates of spontaneous abortion were highest in women < 25 years (20%) and > 35 years (18%) . Preeclampsia rates were higher in women with maternal age > 35 years (27%). This systemic revealed significantly higher risk of maternal and fetal complications in women with kidney transplants. Hypertension, gestation diabetes are the common risk factor among transplant recipients before conception which lead to high rates of stillbirth and neonatal mortality due to premature delivery. The rate of cesarean section was high might be attributed to fetal and maternal complications. The ideal time of conception in women with renal transplant is between 1 and 2 years after transplantation. The limitation of this systemic review include inconsistencies in the definition of live birth rate amongst different studies. Reporting bias may have affected the miscarriage rate. Unable to account for differences in socioeconomics, and healthcare conditions among the different geographic regions. No data for pregnancy outcomes in relation to immunosuppression regimens. The strength of this systemic review include large number of pregnant renal transplant recipients from all around the globe, thus providing us with information about pregnancy outcomes for a heterogeneous population. In conclusion, renal transplant confer risks for both mother and fetal adverse outcome. Future research should focus on type of immunosuppression and its correlation with specific pregnancy outcomes; and evaluation of risk factors associated with specific maternal and fetal adverse events.
What is the level of evidence of this study?
This meta-analysis So the level of evidence is 1
ESRD affects the reproductive system due to Disturbed hypothalamic-pituitary gonadal axis leads to hormonal profile problems , loss of libido. After renal transplant fertility improves in a few weeks and full restorations may happen as early as 6 months , so Contraception should be planned prior to transplantation to minimize the risks, optimal conditions for a pregnancy when desired, and to suggest What is the safety profile of immunosuppressive therapy in pregnancy & lactation and Planning contraception.
Maternal outcome : cesarean section was 62.6%
rates of preeclampsia was 21.5% pregnancy induced hypertension was 24.1%
gestational diabetes was 5.7%
Fetal outcomes
rate of preterm birth was 43.1%
The mean gestational age for newborns was 34.9weeks
the mean birth weight was 2470 g
Graft outcomes
The overall acute rejection rate during pregnancy was 9.4%
With regards to graft failure, there was large variability in the follow up period ranging from 1 year to 14 years. However among 489 recipients in 12 studies where two-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%)
Time of conception. Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3year interval following kidney transplant as compared to 3 year interval.
AMAL Anan
2 years ago
What is the level of evidence of this study?
Level of evidence I meta-analysis.
fakhriya Alalawi
2 years ago
1. Level 1 evidence
2. Summary: Pregnancy in a kidney transplant recipient continues to remain challenging due to risk of adverse maternal complications as well as the risk of adverse fetal outcomes. Additionally, there is risk of side effects from immunosuppressive medication, and risk of deterioration of allograft function.
In this analysis t, Shah, S. et al, reported a higherrates of preeclampsia 21.5% (depending on geographical distribution), a higher cesarean section rates of 62.6%, gestational diabetes was 5.7% and pregnancy induced hypertension was 24.1%. The rate of other pregnancy outcomes was as follows: induced abortions (12.4%; 95% CI, 10.4–14.7), miscarriages (15.4%; 95% CI, 13.8–17.2), stillbirths (5.1%; 95% CI, 4.0–6.5), ectopic pregnancies (2.4%; 95% CI, 1.5–3.7), preeclampsia (21.5%; 95% CI, 18.5–24.9), gestational diabetes (5.7%; 95% CI, 3.7–8.9), pregnancy induced hypertension (24.1%; 95% CI, 18.1–31.5), cesarean section (62.6, 95% CI 57.6–67.3), and preterm delivery was 43.1% (95% CI, 38.7–47.6). The rate of spontaneous abortion was higher in women with mean maternal age < 25 years and > 35 years as compared to women aged 25–34 years.
The risk of adverse fetal outcomes of premature birth, low birth weight, and small for gestational age infants remained high. The live-birth rate was 72.9% (95% CI, 70.0–75.6). The rate of preterm birth was 43.1% (95% CI, 38.7–47.6) defined by babies born alive before 37 weeks of gestation, and neonatal mortality was high across all geographical regions was 3.8% (95% CI, 2.8–5.2).
The 2–3-year interval following kidney transplant had Maternal complication of preeclampsia and higher neonatal mortality, and lower rates of live births as compared to > 3 year, and < 2-year interval.
Overall, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making.
Live birth rate was 72.9% ( higher than general population ) , miscarriages rate was 15.4% ( lower than general population in USA but higher in Africa & South America ) , induced abortions rate was 12.4% , stillbirths rate was 5.1% (higher than the US general population (5.1% vs. 0.6%) . Worldwide, stillbirth rate was highest in Asia , and lowest in Africa ) and rate of ectopic pregnancies was 2.4% .
Maternal outcomes:
– Preeclampsia & Pregnancy-induced hypertension were higher than general population (21.5% & 24.1 respectively ) –Cesarean section was 62.6% ( high ) -Gestational diabetes was 5.7%.
Fetal outcomes
The rate of preterm birth was 43.1% ( live birth before 37 weeks of gestation) neonatal mortality was 3.8%
Graft outcomes
The overall acute rejection rate during pregnancy 9.4% which is comparable to the general population )
Conclusions:
This meta analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients with data spread over different decades from all over the world shows favorable outcomes with live birth rates exceeding that in the recent national population. Majority of patients preserve their graft. However, pregnancy after renal transplant confers significant risk in terms of maternal and fetal adverse events, including increased rates of preeclampsia, gestational diabetes, cesarean section rates, and pregnancy induced hypertension. The risk of prematurity and low birth rate are also high.
Wael Jebur
2 years ago
Its a meta analysis to assess the outcome of pregnancy in kidney transplant patients.
Infertility is usually improving and most post transplant patients will regain there fertility within few months ,due to restoration of normal hypothalamic, pituitary adrenal axis. function. Nevertheless , pregnancy post transplantation is not as safe as its in normal pregnancy. with multiple maternal ,fetal and allograft comorbidities challenging the outcome.
This meta analysis study performed to address this issue .
pregnancy outcomes as shown by the study:
1] Majority of post transplant pregnancies result in life birth.
2] In the Cohort considered for analysis,25% of them had serious pregnancy related complications
3]The live birth rate in post transplant pregnancies is higher than the general population rate ,a finding that might reflect a reporting bias or a selection bias as in which only healthy kidney transplant women pursue pregnancy;
4] 25% higher rate of pre eclampsia, 6 times higher rate than general population.
5]Hypertension is a common finding in transplant patients and higher post transplantation 50-60%. Transplantation related factors that induced hypertension include, immunosuppressants {CNi and CS}, donor type, obesity, alcohol, smoking, allograft function , and presence of native kidney{due to Renin over production}.
6] higher rate of Diabetes Mellitus ,however with variable rates in different geographical regions, from 1% to 8.9%, Which is obviously linked to CNi and Cs and importantly influenced by ethnicity.
7] Stillbirth and neonatal mortality are higher than the rate in general population, it could be related to higher incidence of pre eclampsia , proteinuria, hypertension allograft dysfunction with creatinine of more than 1.5 mg/dl.
8] The rate of cesarean section is double the rate in general population. ranging between 60 to 77 %, attributed to fetal and maternal complications.
9] Premature delivery reported in 50 % of live birth ,attributed to pre eclampsia, fetal complications and renal compromise are main indications for premature delivary.
10]maternal and fetal complication were higher in pregnancies during the first 2 years post transplantations.
the study is meta analysis with level of evidence 1
manal jamid
2 years ago
Reproductive system function in women with end stage renal disease is decreased due to Disturbed hypothalamic-pituitary gonadal axis, disturbed hormonal profile (H prolactin, H FSH, H LH, lack of LH surge, L estradiol, L progesterone) Infertility- anovulation- menstrual irregularities- loss of libido.
It all start to improve in a few weeks after renal transplantation & full restorations may happen as early as 6 months. However, pregnancy remains challenging due to the risk of adverse clinical outcomes. on mother, fetous as well as in the graft.
Contraception should be planned prior to transplantation to minimize the risks, optimal conditions for a pregnancy when desired, and to suggest What is the safety profile of immunosuppressive therapy in pregnancy & lactation and Planning contraception.
Despite that live birth rates are comparable to the general population, pregnancy rate is lower and is noted to decline over the years. Likely related to, introduction of MMF, Improved contraceptive counselling, longer waiting time on the transplant list and older maternal age at transplantation. cohort (Fig. 1).
Three studies were from Africa, 31 from Asia, 31 from Europe, 10 from North America, 4 from Oceania, and 8 from South America. Overall, there were 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years. What is the level of evidence of this study?
This meta-analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients with data spread over different decades from all over the world.
So the level of evidence is 1 Summarize the pregnancy outcome presented by this study? Pregnancy outcomes:
– Live birth rate was 72.9% higher as compared to the US general population and favorable across all geographic regions
– miscarriages rate was 15.4%, higher across Africa and South America.
-induced abortions rate was 12.4% highest in South America, followed by Asia, Oceania, North America, Europe, and Africa
stillbirths rate was 5.1 was highest in Asia and lowest in Africa
Ectopic pregnancies were 2.4 with highest rate in Asia Maternal outcomes
– preeclampsia, rates were 21.5 highest in Oceania, followed by North America and lowest in Africa
-Cesarean section was 62.6% was highest in South America, followed by Africa
-Gestational diabetes was 5.7%, Oceania had the lowest rates.
pregnancy induced hypertension was 24.1% highest in South America while lowest in Africa. Fetal outcomes:
– Preterm birth was 43.1% defined by babies born alive before 37 weeks of gestation, being highest in South America and lowest in North America.
-Neonatal mortality was 3.8% with the highest rate being in Africa and lowest rate in North America.
The mean gestational age for newborns was 34.9 weeks and the mean birth weight was 2470 g. Graft outcomes.
Acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% was highest in Asia , followed by South America.
Graft failure among 489 recipients in 12 studies where two-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%). Time of conception.
Abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to < 2 year interval and > 3 year interval .
Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year interval than < 2 year interval.
Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and < 2 interval. Maternal age for conception.
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years.
Spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years.
Preeclampsia rates were higher in women with maternal age > 35 years and 29–34 years followed by < 25 years and 25–29 years. Conclusion: Although the outcome of live births is favorable, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making
Mohammed Sobair
2 years ago
What is the level of evidence of this study?
Level of evidence 1.
Kidney transplantation offers the best hope to women with end-stage renal disease who
wish to become pregnant.
Pregnancy outcomes:
Live birth rate was 72.9%. Favorable across all geographic regions.
Miscarriages rate was 15.4%. Higher across Africa 21%, and South America 20.2%.
Induced abortions rate was 12.4% , The rate of induced abortion was highest in South
America 19.8%; followed by Asia 13.3%, Oceania11.5%, North America 10.9%; , Europe
10.0%; , and Africa 7.7%
Stillbirth’s rate was 5.1%.
Stillbirth rate was highest in Asia 6.6%, and lowest in Africa 2.6%,
Ectopic pregnancies was 2.4%.
With highest rate in Asia 3.3%.
Maternal outcomes:
Overall, rates of preeclampsia was 21.5% .
Cesarean section was 62.6%
Gestational diabetes was 5.7% .
Pregnancy induced hypertension was 24.1%.
Preeclampsia rate was highest in Oceania 27.0%, followed by North America 25.5%;
and lowest in Africa 10.5%. Cesarean section rate was highest in South America,
followed by Africa 77%.
Worldwide, Oceania had the lowest rates of gestational diabetes 1.0%.
With regards to pregnancy induced hypertension, highest rate was reported in South
America 48.0%,
While lowest rate was in Africa 16.1%.
Fetal outcomes:
Rate of preterm birth was 43.1%, and neonatal mortality was 3.8%.
Rates of preterm birth was highest in South America 55.0%, and lowest in North America
35.4%, the mean gestational age for newborns was 34.9 weeks.
Mean birth weight was 2470 g.
Neonatal mortality was high across all geographical regions as compared to the US
mean (3.8% vs. 0.4%), with highest rate in Africa 18.4% and lowest rate in North
America 1.3%.
Graft outcomes:
Acute rejection rate during pregnancy was 9.4%, which was comparable to the US
mean of 9.1%. Rates of acute renal allograft rejection were highest in Asia (11.0%),
followed by South America (10.7%), Oceania (9.1%), Europe (7.3%), north America
(6.7%), and Africa (4.8%).
Time of conception:
Stratified by interval of < 2 years, 2–3 years, and > 3 years between pregnancy and
kidney transplant .
Induced abortion rates and neonatal deaths were highest in the 2–3 year interval
following kidney transplant as compared to < 2 year interval and > 3 year interval.
Cesarean section rate and live birth rate were also less favorable in this interval of 2–3
years than > 3 year, and < 2 year interval.
Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year
interval than < 2 year interval .Spontaneous abortion rates were highest in > 3 year
interval followed by 2–3.
Maternal age for conception:
Lower live birth rate was observed in women with maternal age 29–34 years than those
< 29 years (74% vs. 76 %.).
Rates of spontaneous abortion were highest in women < 25 years and > 35 years
followed by women with maternal age 25–34 years.
Preeclampsia rates were higher in women with maternal age > 35 years 27%.
Radwa Ellisy
2 years ago
-level of evidence 1
-Shortly after transplantation fertility could be regained (within 6 month), so ideally speaking pregnancy must be planned rather than contraindicated.
A meta-analysis was performed to track pregnancy-related maternal and fetal outcomes worldwide and address their incidence as a primary outcome.
It included 6712 pregnancies in 4174 transplant recipients encountered in 87 studies
Revealed pregnancy outcome
1- Successful pregnancy rate was 72.9%*
*This rate is more than the general population 62% may be due to that these pregnant women receive better care from different specialities, the difference in data reporting he’s rate either per 1000 or per 100000 pregnant women, or due to the exclusion of recipient received MMF and other teratogenic drugs from studies
2- miscarriages rate was 15.4%
3- induced abortions rate was 12.4%
4- stillbirths rate was 5.1%
5- ectopic pregnancies was 2.4% Maternal outcomes
1- preeclampsia was 21.5%
2- cesarean section was 62.6% – highest in South America
3- gestational diabetes was
4- Pregnancy-induced hypertension was 24.1% Fetal outcomes
1- preterm birth (before 37 weeks) was 43.1%
2- neonatal mortality was 3.8%
3- Mean gestational age for newborns was 34.9 weeks Graft outcomes
1- Acute rejection rate 9.4%
2- two-year post pregnancy graft loss was reported among 489 recipients in 12 studies where s to be (9.2%).
Last edited 2 years ago by Radwa Ellisy
Drtalib Salman
2 years ago
What is the level of evidence of this study?
level of evidence of 1
Summarise the pregnancy outcome presented by this study
pregnancy outcomes
Live birth rate was 72.9%.
miscarriages rate was 15.4%.
induced abortions rate was 12.4%
stillbirths rate was 5.1%
ectopic pregnancies was 2.4% (95% CI, 1.5–3.7).
Maternal outcomes :
rates of preeclampsia was 21.5%.
cesarean section was 62.6%
gestational diabetes was 5.7%.
pregnancy induced hypertension was 24.1% .
Graft outcomes
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%.
Time of conception Outcomes were also stratified by interval of < 2 years, 2–3 years, and > 3 years between pregnancy and kidney transplant.
induced abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to < 2 year interval and > 3 year interval (16% vs. 11% vs. 10, and 9% vs. 3% vs. 4% respectively).
Cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years than > 3 year, and < 2 year interval (68% vs. 75% vs. 74, and 73% vs. 65% vs. 42% respectively).
Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year interval than < 2 year interval (24% vs. 23% vs. 13%).
Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and < 2 interval (16% vs. 14% vs. 10%).
Maternal age for conception Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs. 76%).
Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
Mahmud Islam
2 years ago
This is a meta-analysis with level evidence of I
In this meta-analysis evaluating 6712 pregnancies (4174 women) live birth was 72.9 %, miscarriage 15.4%, stillbirths 5.1%, and ectopic pregnancy 2.4%. these percentages varied with respect to rates of the general population according to the place of follow-up.
In terms of maternal outcomes associated with pregnancies, the overall preeclampsia rate was 21.5%. C/S was performed in 62 % of cases.
In 822 kidney transplant recipients evaluated, the acute rejection rate during pregnancy was 9.4%. post-delivery follow-up varied among studies but 489 recipients (from 12 studies) were evaluated and 32 cases (9.2%) were reported. Follow-ups varied from 1 to 14 years. In sum, the rate of stillbirth, preeclampsia and C/s was higher than the general population. gestational diabetes, as well as rejections, were not well evaluated because of individualizing of treatments.
Ahmed Abd El Razek
2 years ago
Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review.
Level of evidence is 1.
Summary of pregnancy outcomes:
This meta-analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients shows favorable outcomes with live birth rates and majority of patients preserve their graft.
However, pregnancy after renal transplant has significant risks of maternal and fetal adverse events, including increased rates of preeclampsia, gestational diabetes, cesarean section rates, and pregnancy induced hypertension. The risk of prematurity and low birth rate are also high.
Pregnancy outcomes:
Kidney transplant recipients, live birth rates were higher as compared to the US general population (72.9% vs.62%).
Miscarriage rate was slightly lower than that of the US general population (15.4% vs. 17.1%). But higher across Africa and South America.
Induced abortion rate was also lower than the US general population (12.4% vs. 18.6%).Being highest in South America, followed by Asia, Oceania, North America, Europe and Africa.
Stillbirth rate was higher than the US general population (5.1% vs. 0.6%).Worldwide, stillbirth rate was highest in Asia and lowest in Africa.
The rate of ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%), with highest rate in Asia.
Maternal outcomes:
Rates of preeclampsia was 21.5%, cesarean section was 62.6%, gestational diabetes was
5.7%, and pregnancy induced hypertension was 24.1%.
Preeclampsia rate was highest in Oceania, followed by North America, and lowest in Africa.
Cesarean section rate was highest in South America followed by Africa.
Oceania had the lowest rates of gestational diabetes.
Pregnancy induced hypertension, highest rate was reported in South America, while lowest rate was in Africa.
Fetal outcomes:
Rate of preterm birth was 43.1% being highest in South America and lowest in North America.
Neonatal mortality was high across all geographical regions with highest rate in Africa and lowest rate in North America.
Graft outcomes:
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%.
Rates of acute renal allograft rejection were highest in Asia (11.0%), followed by South America
(10.7%), Oceania (9.1%), Europe (7.3%), North America (6.7%), and Africa (4.8%).
There were 32 cases of graft loss (9.2%) were reported.
The change in preconception creatinine and post-pregnancy creatinine, was statistically significant (1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007).
Maternal age for conception:
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs.76%).
Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
saja Mohammed
3 years ago
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review What is the level of evidence of this study?
level 1 of evidence (Metanalysis and systematic review)
Summarize the pregnancy outcome presented by this study ABSTRUCT:
Male and female Fertility fully recovered early post-transplant period in the first 1-6 months .Pregnancy post-transplant still encouraged with more medical and surgical challenges that affect the mother, fetus and the graft .Proper counselling should be done at time of transplant work up addressing all the potential medical and surgical risk to the mother ,fetus and the kidney graft and avoid unplanned pregnancy especially in the first two years after transplant due to high risk of infections , rejection , intense immunosuppression with its associated maternal and fetal risks including hypertension , proteinuria preeclampsia , UTI including pyelonephritis , rejection , CNI toxicity AIM
Comprehensive metanalysis and systematic review of the all-registered retrospective studies or case series based, observational studies of pregnancy outcome in kidney transplant recipients, worldwide and assess the incidence of pregnancy post-transplant and The secondary outcome were examine the effect of pregnancy on the kidney allograft loss, allograft rejection, identify ideal motherly age of conception, and determine ideal time of conception between kidney transplant and pregnancy Method: review of the available studies of pregnancy in kidney transplant from PubMed Cochrane database, midline and embase, Elsevier Scopus, Expanded, citation-index from 2000-2017
Exclusion criteria include non-English studies, studies with overlap cohort results, multiple organ transplant, case series with < 10 cases, double records
Data extraction and analysis by three independent data-extraction teams with double check and analysis of the data Results:
87 studies match with inclusion criteria of more than 6712 pregnancy in > 4600 recipients with mean maternal age of 29, with live birth rate > 72 %, and miscarriage rate 15.4%, abortion 12.4 %, stillbirth 5.1%, ectopic pregnancy 2.4%, preeclampsia rate 21%, pregnancy induced hypertension 24%, GDM 5.7%, CS rate higher in kidney transplant reached up to 62%, premature birth preterm > 40% with mean gestational age of 34 weeks and low birth wt with mean of 2450 with higher neonatal mortality in 2-3 years post transplantation
Maternal outcome
1-Over all pregnancy post-transplant associated with higher rate of preeclampsia, GDM, PIH, CS, proteinuria.
2-Cesarean section rate was highest in South America (88.8%) followed by Africa (77.5).
3- pregnancy induced hypertension (PIH) highest rate was in South America (48.0% while
lowest rate was in Africa (16.1%)
4- Oceania had the lowest rates of gestational diabetes (1.0%) but higher rate of preeclampsia
(27.0%). Fetal outcome
1-favorable outcomes with live birth rates above that in the recent national population
2-fetal preterm birth was 43.1% highest in south America > 55% and lowest in north America 38%
3-Neonatal mortality was high across all geographical regions as compared to the US mean (3.8% vs. 0.4%).
4-The risk of prematurity and low birth rate are also high. Which need more studies including the type of immunosuppression and its correlation with specific pregnancy outcomes. Graft outcome
Majority of patients preserve their graft function with overall lower rate of rejection around 9% however higher rate of rejection found in specific ethnic back ground like Asia 11% followed by south America 10.7 while in Europe 7.2 %, Africa even lower 4.8 %. Maternal age for conception:
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs.76%)
Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women
with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal
age > 35 years (27%) and 29–34 years (26%) followed by
< 25 years (17%) and 25–29 years (14%) Time of conception:
the best time for conceptions’ between 1-2 years , not 2-3 years or more than 3 years as the rate of fetal loss and neonatal death higher.
Strength of the study
1- Large sample size reflects the pregnancy outcome from different populations
2-Address Region specific pregnancy related outcome
3-Identify the pregnancy outcome in specific risk group both will allow to generate specific recommendation for such specific region and risk group to be followed
Limitation of the study
1-Assessing the pregnancy outcome from data spread over different decades.
2-limitation of the retrospective study design, small numbers, and likely reporting bias associated with data from intended registries.
3-unable to account for differences in socioeconomics, and healthcare conditions among the different geographic regions. Due to lack of individual patient data,
4-unable to assess pregnancy outcomes in relation to immunosuppression regimens.
Ahmed Omran
3 years ago
Meta-analysis and systematic review ;Level I
This review included 87 studies, over a long-time frame (from 2000 to 2017), including 6712 pregnancies in 4127 kidney transplant recipients. The outcomes were as follows:
* Higher rates of live births than general population, 50% having preterm delivery. Lower live birth rates in women in the age group 29-34 years and spontaneous abortions were least in the 25-34 years aged women.
* About 25% had serious complications related to pregnancy with higher rates of stillbirths and ectopic pregnancies compared with general population
* Lower rates of miscarriages and induced abortions .
* Preeclampsia was 6 times higher compared with general population
* Cesarean sections were twice the general population
* Gestational diabetes mellitus was less common in the transplant recipients.
* Pregnancy induced hypertension was seen 25% of the transplant recipients.
*Approximately 10 times higher neonatal mortality shown in transplant recipients.
* Mean birth weight was less than 2500 grams and mean gestational age for newborns was 34.9 weeks in transplant recipients.
*Acute rejection rates were similar to the non-pregnant transplant recipients.
*Time of conception had impact on pregnancy outcomes; with lowest live birth rates and highest neonatal deaths seen among pregnancies in 2-3 year interval post-transplant. CS and preeclampsia were higher after 2 year interval.
* Fetal outcomes were found better in pregnancies within 2 years post-transplant, but could be biased by reporting.
* Graft function was preserved in majority of patients.
.
Hinda Hassan
3 years ago
What is the level of evidence of this study? This meta-analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients with data spread over different decades from all over the world. So the level of evidence is 1 Summarize the pregnancy outcome presented by this study? Pregnancy outcomes: Live birth rate was 72.9% with the lowest rate is in Africa followed with Asia. Miscarriages rate was 15.4% with the highest rate again in Africa and in South America. Induced abortions rate was 12.4% with highest rate in South America followed by Asia, Oceania, North America, Europe and Africa. Stillbirths’ rate was 5.1% with the highest rate present in Asia and lowest is in Africa. Ectopic pregnancies was 2.4% with highest rate is in Asia. Maternal outcomes: Rates of preeclampsia was 21.5 % % with the highest rate in Oceania followed by North America and lowest in Africa. Cesarean section rate was 62.6% which was highest in South America followed by Africa. Gestational diabetes rate was 5.7% with the lowest rate in Oceania. Pregnancy induced hypertension rate was 24.1 and being highest in South America and lowest in Africa. Fetal outcomes: Rate of preterm birth was 43.1% defined by babies born alive before 37 weeks of gestation, being highest in South America and lowest in North America. Neonatal mortality was 3.8% with the highest rate being in Africa and lowest rate in North America. The mean gestational age for newborns was 34.9 weeks and the mean birth weight was 2470 g. Graft outcomes: The overall acute rejection rate during pregnancy was 9.4% being highest in Asia followed by South America, Oceania, Europe, North America and Africa. Graft failure showed large variability in the follow up period ranging from 1 year to 14 years. The two-year post pregnancy graft loss reported was 9.2%. The change in preconception creatinine and post-pregnancy creatinine was statistically significant (1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl). Time of conception Outcomes were stratified by interval between pregnancy and kidney transplant into: Ø < 2 years Ø 2–3 years Ø 3 years Adverse pregnancy outcomes ofinduced abortion rates and neonatal deaths were highest in the 2–3 year interval (16% and 9%), following kidney transplant as compared to < 2 year interval (11% and 3%) and > 3 year interval (10 and 4%). Cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years (68% and 73%) than > 3 year( 75% and 65%) and < 2 year interval ( 74 and 42%). Maternal complication of preeclampsia was higher in the 2–3 interval , and > 3 year interval than < 2 year interval (24% vs. 23% vs. 13%). Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and<2 interval (16% vs. 14% vs. 10%). Maternal age for conception: Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs. 76%). Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%). Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
Akram Abdullah
3 years ago
The level of this study is a level 1 meta-analysis review.
Summarise the pregnancy outcome presented by this study?
87 studies meta-analysis between 2000-2017 discussed the outcome of pregnancy post kidney transplant, there were 6712 pregnancies in 4174 kidney transplant recipients. Pregnancy outcomes as compared to the general population:
higher rates of Live birth.
Lower rates of Induced abortion & miscarriage.
Higher rate of Stillbirth.
Slightly higher rate of Ectopic pregnancy.
Maternal outcomes: * Preeclampsia was 21.5% * Cesarean section was 62.6% * Gestational diabetes was 5.7%. * Pregnancy-induced hypertension was 24.1% Fetal outcomes
The rate of preterm birth was 43.1% ( babies born alive before 37 weeks of gestation)
neonatal mortality was 3.8% Graft outcomes
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%. Time of conception: The best time of conception after renal transplantation remains an area of controversy. According to American Society of Transplantation guidelines, the ideal time is between 1 and 2 years after transplantation .
** What is the level of evidence of this study?
Level of Evidence 1
Meta-Analysis Systemic Reviews
** Summarise the pregnancy outcome presented by this
# This meta analysis of 87 studies from (2000 to 2017) conducted the outcomes of pregnancy in kidney transplanted women , there were 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years.
# Pregnancy outcomes as compared to the general population:
* Live birth rates were higher compared to the US general population (72.9% vs. 62%).
* Miscarriage rate was slightly lower than US general population (15.4% vs. 17.1%), but higher in Africa (21.0%) and South America (20.2%).
* Induced abortion rate was lower than the US general population (12.4% vs. 18.6%), but it was highest in South America (19.8%), Asia (13.3%), Oceania (11.5%), North America (10.9%), Europe (10.0%) and Africa (7.7%).
* Stillbirth rate was higher than the US general population (5.1% vs. 0.6%), but was highest in Asia (6.6% ), and lowest in Africa (2.6% ) .
* Ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%), with highest rate in Asia (3.3%).
# Maternal outcomes:
* Preeclampsia was 21.5% (US, 3.8%).
* Cesarean section was 62.6% (US, 31.9%).
* Gestational diabetes was 5.7% (US, 9.2%).
* Pregnancy induced hypertension was 24.1%.
* Preeclampsia rate was highest in Oceania
(27.0%), followed by North America (25.5%) and lowest in Africa (10.5%)
# Fetal outcomes:
* Preterm birth was 43.1 %( defined by babies born alive before 37 weeks of gestation) was highest in South America (55.0%) and lowest in North America (35.4%).
* Neonatal mortality was 3.8%.
*The mean gestational age for newborns was 34.9 weeks (US mean, 38.7 weeks).
* And the mean birth weight was 2470 g (US mean, 3389 g).
*Neonatal mortality was high across all geographical regions as compared to the US mean (3.8% vs. 0.4%), with highest rate in Africa (18.4%) and lowest rate in North America (1.3%)
# Graft outcomes:
* Acute rejection rate during pregnancy
among 822 kidney transplant recipients was 9.4% which was comparable to the US mean of 9.1%, were highest in Asia (11.0%), followed by South America (10.7%), Oceania (9.1%), Europe (7.3%), North America
(6.7%) and Africa (4.8%).
* With regards to graft failure, the two year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%).
* The change in pre and post pregnancy creatinine, was statistically significant
(1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007).
# Time of conception:
* Outcomes were also stratified by interval of 3 years between pregnancy and kidney Transplant.
* induced abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to 3 year interval (16% vs. 11% vs. 10, and 9% vs. 3% vs. 4% respectively).
* Cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years than > 3 year, and 3 year interval than 3 year interval followed by 2–3 interval, and<2 interval (16% vs. 14% vs. 10%).
# Maternal age for conception:
*Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs. 76%).
*Spontaneous abortion were highest in
women 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
* Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
Level of evidence
1
Pregnancy outcomes
Live birth rate was 72.9%
miscarriages rate was 15.4%
induced abortions rate was 12.4%
stillbirths rate was 5.1%
and rate of ectopic pregnancies was 2.4% .
Maternal outcomes
Overall, rates of preeclampsia was 21.5% cesarean section was 62.6%
gestational diabetes was 5.7%
Fetal outcomes
Overall, rate of preterm birth was 43.1%
defined by babies born alive before 37 weeks of gestation, and
neonatal mortality was 3.8%
Graft outcomes
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% Rates of acute renal allograft rejection were highest in Asia (11.0%), followed by South America (10.7%), Oceania (9.1%), Europe (7.3%), North America (6.7%), and Africa (4.8%)
With regards to graft failure, there was large variability in the follow up period ranging from 1 year to 14 years.
The best time of conception after renal transplantation remains an area of controversy. According to American Society of Transplantation guidelines, the ideal time is between 1 and 2 years after transplantation whereas, European best practice guidelines recommend delaying pregnancy for a period of 2 years after transplantation.
# Pregnancy is very rare in ESKD pts so Tx is the only hope .
#Pregnancy in Tx carries risk on Mother , fetus and the graft .
#Maternal Complications:
*pre-eclampsia: 25 % of cases most common complication
*gestational diabetes 8 % differs according to ethnicity .
*UTI
* CS Complications
#Fetal Complications:
*preterm Labour
*IUGR
*birth defects
*Still birth
#Graft Complications: depend on
Base line KFTs , proteinuria, Graft function , immunosuppression, timing of conception (at least 1 year post Tx)
Summarise the pregnancy outcome presented by this study
women on dialysis have a very low incidence of conception ranging from 0.9 to 7% due to disruption of the hypothalamic gonadal axis. transplantation consider the best hope to women with end-stage renal disease who wish to become pregnant. Pregnancy in a kidney transplant recipient is challenging due to the risk of adverse
· maternal complications (preeclampsia, hypertension, and gestational diabetes)
· fetal outcomes (premature birth, low birth weight, small for gestational age infants, and side effects from immunosuppressive medication).
· deterioration of allograft function.
Therefore, preconception counseling, family planning, and contraception are pertinent parts of the transplant counseling process.
The primary goalof this study was to perform a meta-analysis to systematically identify all studies of pregnancy-related outcomes in kidney transplant recipients from all around the world, and estimate pooled incidence of pregnancy outcomes, maternal complications, and fetal complications. The secondary goalswere to examine the impact of pregnancy on the kidney allograft loss, and allograft rejection, identify the ideal maternal age of conception and determine the ideal time of conception between kidney transplant and pregnancy
And the results showed
· live birth rates were higher as compared to the US general population (72.9% vs. 62%) .
· miscarriage rate was slightly lower than that of the US general population (15.4% vs. 17.1%)
· Induced abortion rate was also lower than the US general population (12.4% vs. 18.6%).
· stillbirth rate was higher than the US general population (5.1% vs. 0.6%).
· The rate of ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%).
· preeclampsia were 21.5% (95% CI, 18.5– 24.9; US mean, 3.8%),
· cesarean section was 62.6% (95% CI, 57.6–67.3; US mean, 31.9%).
· gestational diabetes was 5.7% (95% CI, 3.7–8.9; US mean, 9.2%),
· pregnancy-induced hypertension was 24.1% (95% CI, 18.1–31.5).
Fetal outcomes
· preterm birth was 43.1% (95% CI, 38.7– 47.6) defined by babies born alive before 37 weeks of gestation
· neonatal mortality was 3.8% (95% CI, 2.8–5.2).
· Rates of preterm birth were highest in South America (55.0%), and lowest in North America (35.4%).
· The mean gestational age for newborns was 34.9 weeks (US mean, 38.7 weeks) and the mean birth weight was 2470 g (US mean, 3389 g).
· Neonatal mortality was high across all geographical regions as compared to the US mean (3.8% vs. 0.4%).
Graft outcomes
· The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%, which was comparable to the US mean of 9.1%.
· With regards to graft failure, a two-yearpost-pregnancy graft function was reported, and there were 32 cases of graft loss (9.2%). The change in preconception creatinine and post-pregnancy creatinine, was statistically significant (1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007).
Summarise the pregnancy outcome presented by this study
This meta-analysis included a total of 87 studies, spread over a long-time frame (from 2000 to 2017), involving 6712 pregnancies in 4127 kidney transplant recipients. The pregnancy outcomes of the study are as follows:
1) Higher rates of live births than the general population, with half of them having preterm delivery. Women in the age group 29-34 years showed lower live birth rates. Spontaneous abortions were least in the 25-34 years aged women.
2) Approximately 25% had serious pregnancy related complications with higher rates of stillbirths and ectopic pregnancies than the general population
3) Lower rates of miscarriages and induced abortions seen in transplant recipients.
4) Rates of preeclampsia were 6 times higher than the general population
5) Rates of Cesarean sections were 2 times the general population
6) Gestational diabetes mellitus was less common in the transplant recipients.
7) Pregnancy induced hypertension was seen in one fourth of the transplant recipients.
8) Approximately 10 times higher neonatal mortality was seen in the transplant recipients.
9) Among the transplant recipients. the mean birth weight was less than 2500 grams and mean gestational age for newborns was 34.9 weeks.
10) Acute rejection rates were comparable to the non-pregnant transplant recipients.
11) Time of conception had bearing on pregnancy outcomes with lowest live birth rates and highest neonatal deaths seen among pregnancies in 2-3 year interval post-transplant. Cesarean sections and preeclampsia were higher in pregnancies after 2 year interval.
12) Fetal outcomes were better in pregnancies within 2 years post-transplant, but could be a manifestation of reporting bias.
Overall, the rates of maternal and fetal complications were higher in the transplant recipients, but having a better outcome than general population with preservation of graft function.
What is the level of evidence of this study?
This is a systematic review and meta-analysis with the level of evidence 1
Summary;
Kidney transplantation is believed to be the greatest option for women with end-stage renal illness who aspire to get pregnant; nonetheless, there are several hurdles that must be overcome in order to avoid problems for both the mother and the fetus.
This study uses meta-analysis to locate all studies on pregnancy-related outcomes in kidney transplant patients from all around the globe in a systematic manner.
This study aimed to determine the prevalence of adverse pregnancy outcomes as well as maternal and fetal problems. In addition, the influence of pregnancy on kidney allograft loss and allograft rejection will be investigated, as will the identification of the optimal maternal age at which to conceive and the determination of the optimal period between kidney transplant and pregnancy.
Results:
Women who had major pregnancy difficulties, which included at least one of the following: preterm delivery, first or second-trimester loss, stillbirth, or neonatal mortality, accounted for one-quarter of all women.
When compared to the most current national statistics from the United States, the rates of preterm birth, stillbirth, and infant death were all higher.
Although the live birth rates in women following kidney transplantation were higher than in the general population (73 per cent vs 62 per cent), a study of health utilization in the United States indicated a significantly lower live birth rate in kidney transplant patients (55 per cent).
Preeclampsia was diagnosed in one-quarter of the women, and the incidence of preeclampsia was almost six times greater than in the general US population (21.5 per cent vs. 3.8 per cent).
Because preexisting hypertension and proteinuria are widespread in kidney transplant patients, the diagnosis of superimposed preeclampsia might be challenging in these individuals.
Between different geographical locations, there are statistically significant variances in the incidence of gestational diabetes mellitus.
When compared to the general population, the rates of stillbirth and infant death were much higher in this cohort.
Result of the graft:
– Acute rejection, occurred at a rate equivalent to that of the general population in the United States during pregnancy among kidney transplant patients. (9.4 per cent vs. 9.1 per cent), respectively.
– Between the preconception and post-pregnancy creatinine levels, there was a statistically significant difference in creatinine levels.
kidney transplantation restores fertility and help ESRD women wish to become pregnant
But it has alot of risks on both mother and fetus added to its risk on the graft function.
This meta-analysis systematically identify all studies of pregnancy-related outcomes in kidney transplant recipients from all around the world addressing maternal and fetal complications also the impact of pregnancy on the renal graft .
The study involved 6712 pregnancies in kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years.
Results
Maternal and fetal complications were significantly higher in transplant women than in general women population.
*Pregnancy outcomes;
The 2–3-year interval following kidney transplant had higher neonatal mortality, and lower rates of live births as compared to > 3year, and< 2-year interval.
Among the studied pregnant ladies there were;
– live-birth rate was 72.9% .
Higher incidence of the following:
-Induced abortions 12.4%
-miscarriages in first and second tirmester .
-stillbirths 5.1%.
-preterm delivery.
-ectopic pregnancies 2.4%.
-Mean gestational age was 34.9 weeks, and mean birth weight was 2470g.
*Maternal complications
-preeclampsia was six times more than general population.
-incidence if gestational diabetes (with variation in different countries),pregnancy induced hypertension ,cesarean section ,
And preterm delivery were also higher.
*Graft outcomes
-acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% which was comparable to the US mean of 9.1%.
-there were 32 cases of graft loss (9.2%).
-change in preconception creatinine and post-pregnancy creatinine, was statistically significant.
In Conclusion:
outcome of live births is favorable,despite the risks of maternal and fetal complications which must be fully discussed with the patients ,timing of pregnancy must be considered on planning for pregnancy with close monitoring of graft function, immunosuppression, blood pressure and diabetes.
This is a aystemic review and meta-analysis with level of evidence 1
Summarise the pregnancy outcome presented by this study
Kidney transplantation is a successful treatment for infertility among patient with end stage renal disease. Following transplantation, there is rapid restoration of fertility. There is risk of side effects from immunosuppressive medication, and risk of deterioration of allograft function. Systematic review and meta-analyses reported incidence and outcomes of pregnancy in women with kidney transplant and evaluated incidence and outcomes of pregnancy in women with kidney transplant. 87 were included in the final study cohort. 6712 pregnancies in 4174 kidney transplant recipients. Following outcomes were demonstrated. Pregnancy outcomes
– Live birth rate was 72.9%, live birth rates were higher as compared to the US general population (72.9% vs. 62%).
– Miscarriages rate was 15.4%, miscarriage rate was slightly lower than that of the US general population (15.4% vs. 17.1%).
– Induced abortions rate was 12.4%, induced abortion rate was also lower than the US general population (12.4% vs. 18.6%).
– Stillbirths rate was 5.1%, stillbirth rate was higher than the US general population (5.1% vs. 0.6%).
– Rate of ectopic pregnancies was 2.4%, the rate of ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%).
Maternal outcomes
– Rates of preeclampsia was 21.5%
– Cesarean section was 62.6%
– Gestational diabetes was 5.7%
– Pregnancy induced hypertension was 24.1%
Fetal outcomes
– preterm birth was 43.1%
– neonatal mortality was 3.8%
– mean gestational age for newborns was 34.9 weeks
Graft outcomes
Acute rejection rate during pregnancy was 9.4% comparable to the US mean of 9.1%.
In conclusion, fertility is expected to be restored shortly after kidney transplantation. Most of pregnancies successfully result in live birth, however both maternal and fetal adverse events are common. Rates of preeclampsia, still birth, and cesarean section were significantly higher than in the general population.
What is the level of evidence of this study? I Summarise the pregnancy outcome presented by this study
-It is a systematic review, meta-analyses study represented 6712 pregnancies in 4174 kidney transplant recipients.
– Pregnancies in women after kidney transplant result in live birth but rates of preeclampsia was significantly higher than in the general population.
– Rates of stillbirth and neonatal mortality were significantly higher as compared to the general population.
-Gestational diabetes mellitus was high as 8.9% in Europe as compared to the general population
-The rate of cesarean section was higher than two folds as compared to the general population in the United States and varied from 60 to 77% across different geographical locations.
-There was a high rate of premature births in the transplant population and close to half of the live births were premature deliveries.
-The best time of conception in women with renal transplant is between 1 and 2 years after transplantation according to guidelines by the American Society of Transplantation, whereas European best practice guidelines recommend
delaying pregnancy for 2 years after transplantation.
– Live birth rate was lowest and neonatal deaths were highest in the 2–3 year
the interval following a kidney transplant.
-Maternal complications of cesarean section and preeclampsia were higher in the 2–3 and >3year interval post-transplant.
-Majority of patients preserve their graft function.
Summarise the pregnancy outcome presented by this study :
ESRD females have impaired fertility due to disruption of hypothalamic gonadal axis. with hemodialysis, successful pregnancy is extremly rare, about 2 %.
Reproduction improves in ESRD females after having renal transplant. some patients restore fertility within 6 months post-transplantation. So, renal transplantation is the best hope for those ESRD women.
However, pregnancy remains a challenging hope as it involves some maternal and fetal risks associated with this pregnancy.
there is limited data on clinical outcome of pregnancy in renal transplant patients.
this study was a meta analysis one for evaluation of pregnancy outcome in these patients. it included an 87 studies of a total number of 1343 due to strict inclusion criteria. it included a total 6712 pregnancies in 4174 patients. the conclusion was the following :
1- the overall outcome is favorable with live birth rates and the majority of patients preserve their grafts.
2- there was an increase in rates of maternal complications as pre-eclampsia,gestational DM, pregnancy induced hypertension as well as cesarean sections.
3- there was an increase in rates of fetal complications as prematurity and low birth weight.
4- finally, more larger studies are still needed for addressing the type of immunosuppression and its correlation with specific pregnancy outcome. also, the risk factors associated with specific maternal and/or fetal outcomes are still to be known.
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review
Level 1 study
summary of the article:
the aim of the study was: 1- to determine the outcome of pregnancy 2- to determine the impact of the pregnancy on the graft
The mean maternal age was 29.6 ± 2.4 years and the mean interval between kidney transplant and pregnancy was 3.7 years.
Pregnancy outcomes:
1- Live birth rate was higher as compared to the US general population (72.9% vs 62%) and was favourable across all geographic regions. This may reflect selection bias or reporting bias in which relatively healthy women decided to pursue pregnancy and also receive better medical support by multiple specialities. 2- Miscarriage rate was slightly lower than that of the US general population (15.4% vs 17.1%), but it was higher across Africa and America. 3- Induced abortion rate was lower than US general population (12.4% vs 18.6%), which was higher than in other regions. 4- Stillbirth rate was higher than in other populations all over the world. which can be explained by prematurity, preeclampsia, and hypertension. 5- Ectopic pregnancy was high as well.
Maternal outcomes:
Pregnancy of Kidney transplant recipients was more liable to the following complications if compared to the general population
1- Preeclampsia which was of a higher rate, sixfold higher as compared to the general US population (21.5% vs 3.8%). 2- Cesarean section (62.6% vs 31.9%). This high rate can be explained by the high fetal and maternal complications among these women. 3- Gestational diabetes which increased in this type of woman as a result of immunosuppressive medication use. 4- Pregnancy-induced hypertension 24.1% Fetal outcomes:
Pregnancy of kidney transplant recipients is associated with the following fetal outcomes:
1- Preterm birth (43.1%), the mean GA was 34.6 wks as compared to US 38.7 wks 2- Neonatal mortality (3.8%) which is high across all geographical regions 3- Low birth weight ( 2.47 g vs 3.389 g)
Graft outcomes:
1- Acute rejection, its rate during pregnancy among kidney transplant recipients was comparable to that in US general population. (9.4% vs 9.1%).
2- The change in creatinine, was statistically significant between the preconception and post-pregnancy creatinine.
Time of conception:
The best time of conception after renal transplantation remains an area of controversy. According to American Society of Transplantation guidelines, the ideal time is between 1 and 2 years after transplantation whereas, European best practice guidelines recommend delaying pregnancy for a period of 2 years after transplantation.
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review
What is the level of evidence of this study ?
Level 1
Summary of pregnancy outcome presented by this study;
1-In women with kidney transplant ,the rates of preeclampsia, still birth, and cesarean section were significantly higher than in the general population.
2- A quarter of women were found to have serious pregnancy complications, defined as at least one of preterm delivery, first or second trimester loss, stillbirth, or neonatal death.
3- The live birth rates in women after kidney transplant were higher than in the general population and this trend was consistent throughout the globe .
4- The rates of preeclampsia were almost six fold higher as compared to the general US population .
5- The increased rate of gestational diabetes in kidney transplant patients can be well explained by the use of immunosuppressive medications like steroids and calcineurin inhibitors, the striking differences between rates of gestational diabetes accord-
ing to geographic location also highlights the importance of predisposition to diabetes due to ethnicity.
6- The rates of stillbirth and neonatal mortality were significantly higher as compared to the general population.
7- The rate of cesarean section was higher than two folds as compared to general population in United States.
8- The overall acute rejection rate during pregnancy among kidney transplant recipients was comparable to the US mean of 9.1%.
9-The change in preconception creatinine and post-pregnancy creatinine, was statistically significant.
The strength of this study ;
1-It involves a large number of pregnant renal transplant recepients from all around the globe, thus providing us with information about pregnancy outcomes for a heterogenous population.
2-It analyzed specific outcomes and identified outcomes which may require intensive management pertaining to that region.
The limitations of the study;
1- It examined pregnancy outcomes over several decades. While it is expected for the outcomes to change due to improvement in obstetric care in kidney transplant recipients over the course of time, subgroup analysis for studies from 2000 to 2017 showed consistent results.
2-There were inconsistencies in the definition of live birth rate amongst different studies that may have affected the results. Reporting bias may have affected the miscarriage rate.
3- It unable to account for differences in socioeconomics, and healthcare conditions among the different geographic regions.
Conclusion;
Although the outcome of live births is favorable, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making.
The fertility is significantly reduced in patients who in haemodialysis due to disruption of hypothalamic pituitary axis. Following transplantation fertility potential usually restores soon . In such situation the pregnancy is a challenge due to high risk of hypertension, pre eclempsia and fetal risks like premature births, low foetal weight and small for gestational age. There can be risks due to immunosuppression and graft dysfunction . Pre conception counselling is very important in such females. The purpose of this study was to perform meta analysis to identify all studies on pregnancy related outcomes in kidney transplant recipients and fetal complications. Also impact of pregnancy on graft loss, rejection. ideal age for conception and ideal time between transplant and pregnancy was assessed
Methodology– 4174 pregnant kidney transplant recipients out of 6712 pregnancies were enrolled.
Pregnancy Outcomes.
Still birth was higher (5%)than general population ( 0.6%)and rate of ectopic pregnancy was also high-2.4 % vs 1.4. Induced abortion and miscarriage rates were lower than US general population
Maternal outcomes.
There was twofold higher rate of C section in kidney transplant recipients as compared to general population. The rate of pre eclempsia was 6 fold higher as compared to general population likely due to factors like immunosuppressants , smoking obesity etc. Rate of of gestational diabetes was related to ethnicity.
Fetal Outcomes
Neonatal mortality was higher in African then North Americans.
Graft Outcomes
Acute rejection was noted in 9.4% while rate in general was 9.1%.
Conclusions.
It shows good outcome in term of live birth in renal transplant recipients however there are risk in terms of maternal and fetal adverse events
More studies needed in terms of type of immunosuppressive therapy in pregnancy and its specific outcomes.
I. Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review What is the level of evidence of this study? Level I evidence;metaanalysis & systematic review ============================================= Summarise the pregnancy outcome presented by this study Pregnancy outcomes after transplant:
· Higher live birth rates versus general population (73% vs.62%); universally consistent. These higher rates may reflect that relatively healthy women decided to conceive, & subsequently received better service by many specialties.
· Miscarriages slightly lower than that of the US general population (15.4% vs. 17.1%);higher in Africa (21.0%), & South America (20.2%)
· Induced abortion highest in S. America (19.8), followed by Asia (13.3%), Oceania (11.5%), N. America (10.9%), Europe (10.0%), & Africa (7.7%)
· Ectopic pregnancies 2.4%
· Stillbirths higher than the US general population (5.1% vs. 0.6%). Worldwide, highest in Asia, & lowest in Africa.
· Ectopic pregnancy slightly higher than the US general population (2.4% vs. 1.4%); highest rate in Asia. ============================== Maternal outcomes:
· Preeclampsia in 21.5% (US, 3.8%)
· Cesarean section was 62.6% (US, 31.9%);highest in S. America (88.8%),followed by Africa (77.5%)
· Gestational diabetes was 5.7% (US 9.2%); lowest in Oceania (1.0%).
· PIH was 24.1%; highest in S. America (48.0%), lowest in Africa (16.1%).
· Preeclampsia rate was highest in Oceania(27%), followed by N. America(25.5%), & lowest in Africa (10.5%) ================================ Fetal outcomes
· Preterm birth (born alive before 37 weeks of gestation)was 43.1%; highest in S. America (55.0%), & lowest in N. America (35.4%)
· Neonatal mortality was 3.8%; high across all regions as compared to the US mean (3.8% vs. 0.4%), with highest rate in Africa (18.4%) & lowest rate in N. America (1.3).
· Mean gestational age for newborns was 34.9 weeks (US mean, 38.7 weeks)
· Mean birth weight was2470 g (US mean, 3389 g). ============================== Graft outcomes
· Acute rejection rate among 822 kidney transplant recipients was 9.4% (95%) which is comparable to the US mean of 9.1%; highest in Asia (11.0%), followed by S. America (10.7%), Oceania (9.1%), Europe (7.3%), N. America (6.7%), & Africa (4.8%).
· Graft loss: among 489 recipients in 12 studies where 2-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%).
· Change in pre- & post-pregnancy creatinine was statistically significant (1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007). ============================== Time of conception
· Induced abortion rates & neonatal deaths were highest in the 2–3 year interval following transplant as compared to < 2 year interval & > 3 year interval (16% vs. 11% vs. 10,& 9% vs. 3% vs.4% respectively).
· C/S rate & live birth rate were less favorable in this interval of 2–3 years than > 3 year, & < 2 year interval (68% vs. 75% vs. 74, & 73%vs. 65% vs. 42% respectively).
· Preeclampsia was higher in the 2–3 interval, & > 3 year interval than < 2 year interval (24% vs. 23% vs. 13%).
· Spontaneous abortion highest in > 3 year interval followed by 2–3 interval, & <2 interval (16% vs. 14% vs. 10%). =============================== Maternal age for conception
· Lower live birth rate in maternal age 29–34 years than those < 29 years (74% vs.76%).
· Spontaneous abortion highest in women < 25 years & > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
· Preeclampsia higher in maternal age > 35 years (27%) & 29–34 years (26%) followed by < 25 years (17%) & 25–29 years (14%). ================================== Conclusions
· This meta analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients shows favorable outcomes with live birth rates exceeding that in the recent national population.
· The graft was preserved in the majority of patients.
· Pregnancy after renal transplant poses significant risk in regards to maternal & fetal adverse events.
· Type of immunosuppression and its correlation with pregnancy outcomes needs to be studied.
· Standardization of definitions used in evaluating these outcomes is needed.
· Health care providers will benefit from this study in their caring for this high risk population.
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review.
Level evidence I. Introduction:
kidney transplantation is considered the best hope to women with end-stage renal disease who wish to become pregnant but also there are many challenges meeting us related to maternal and fetal complications.
Here there is meta-analysis to systematically identify all studies of pregnancy-related outcomes in kidney transplant recipients from all around the world.
To estimate the incidences of pregnancy outcomes, maternal complications, and fetal complications. Also to examine the impact of pregnancy on the kidney allograft loss, allograft rejection, identify ideal maternal age of conception, and determine ideal time of conception between kidney transplant and pregnancy. Results:
Overall, there were 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years data collected from selected 87 studies. Pregnancy outcomes.
Live birth rate was 72.9% which is were higher as compared to the US general population.
Miscarriages rate was 15.4% which was lower than that of the US general population , but higher across Africa , and South America.
Induced abortions rate was 12.4%.
Stillbirths rate was 5.1% which was higher than the US general population.
and rate of ectopic pregnancies was 2.4% . Maternal outcomes.
preeclampsia was 21.5% which was highest in Oceania followed by North America and lowest in Africa.
Cesarean section was 62.6% which was highest in South America , followed by Africa.
Gestational diabetes was 5.7% , Oceania had the lowest rates.
Pregnancy induced hypertension was 24.1% with highest rate was reported in South America , while lowest rate was in Africa. Fetal outcomes.
Preterm birth was 43.1% was highest in South America and lowest in North America.
Neonatal mortality was 3.8% was highest rate in Africa and lowest rate in North America.
The mean gestational age for newborns was 34.9 weeks and the mean birth weight was 2470 g. Graft outcomes.
Acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% was highest in Asia , followed by South America.
Graft failure among 489 recipients in 12 studies where two-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%). Time of conception.
Abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to < 2 year interval and > 3 year interval .
Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year interval than < 2 year interval.
Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and < 2 interval. Maternal age for conception.
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years.
Spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years.
Preeclampsia rates were higher in women with maternal age > 35 years and 29–34 years followed by < 25 years and 25–29 years. Conclusions.
Pregnancy in kidney transplant recipients showed favorable outcomes with live birth rates exceeding that in the recent national population. Majority of patients preserve their graft.
With significant risk in terms of maternal and fetal adverse events, including increased rates of preeclampsia, gestational diabetes, cesarean section rates, and pregnancy induced hypertension so should be considered in patient counseling and clinical decision making. Differences between non-transplant/non-pregnant:
Survival with graft function was comparable to non-pregnant transplant recipient.
Acute rejection rates were similar in pregnant and non-pregnant transplant recipients.
This study is systematic review with level 1 of evidence.
Patients with ESKD have impairment in reproductive system and fertility, with low incidence of conception (0.9-7%), because of disturbance in hypothalamic-gonadal axis.
Kidney transplantation leads to improvement in reproductive function, but pregnancy in kidney transplant recipients is associated with some adverse clinical outcomes.
Pregnancy in kidney transplant recipients is correlated with risk of adverse maternal complications of preeclampsia and hypertension, and risk of adverse fetal outcomes of premature birth, low birth weight, and small for gestational age infants. In addition, increased risk of side effects from immunosuppressive medication, and risk of deterioration of allograft function are reported.
In this systematic review 1343 studies are evaluated and finally 87 met inclusion criteria.
Different factors were evaluated in this systematic review. Pregnancy outcomes consist of Live birth rate was 72.9%, miscarriages rate was 15.4%, induced abortions rate was 12.4%, stillbirths rate was 5.1% and rate of ectopic pregnancies was 2.4%.
In terms of maternal outcomes, Overall, rates of preeclampsia was 21.5%, cesarean section was 62.6%, gestational diabetes was 5.7%, and pregnancy induced hypertension was 24.1%.
Fetal outcomes including Overall, rate of preterm birth was 43.1%, and neonatal mortality was 3.8%.
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%. creatine level changes significantly post pregnancy, compared to pre conception.
Time of conception 2-3 years post-transplant was associated with higher abortion rate, neonatal death, and cesarean section rate. Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3-year interval after transplantation. Lower birth weight rates, and preeclampsia rates were higher in women in older age range.
Both maternal and fetal adverse events are common in post-transplant pregnancies. Rates of preeclampsia, still birth, rates of preterm delivery, cesarean section, and neonatal mortality were significantly higher than in the general population.
The rates of preeclampsia were almost six-fold higher as compared to the general population. Several factors can relate to the onset of hypertension after renal transplantation, consist of the type of immunosuppressive therapy (calcineurin inhibitors and corticosteroids), allograft function, donor type, obesity, alcohol, smoking, and presence of a native kidney (increased production of renin). As a result of higher frequency of preexisting hypertension and proteinuria, diagnosis of superimposed preeclampsia can be difficult in kidney transplant patients.
The rate of gestational diabetes is also higher in kidney transplanted pregnant women possibly due to immunosuppressive medications like steroids and calcineurin inhibitors.
Cesarean section was two-fold of general population. Although vaginal delivery should not be impaired in kidney transplant patients, as the pelvic allograft does not obstruct the birth canal in most patients, exceptionally higher rates of cesarean sections in kidney transplant recipients can be related to fetal and maternal complications.
The ideal time of conception in women with renal transplant is suggested between 1 and 2 years after transplantation.
This study is a meta-analysis study, level 1 evidence. A higher incidence of some medical complications in pregnant transplanted females has been reported compared to non-transplant pregnancies, as follow:2
A. Pre-eclampsia incidence is 24-36% compared to 4-5%.
B. Gestational diabetes incidence is 8% compared to 3.9%.
C. Urinary tract infections (UTI) incidence is 14.6- 42% compared to 7%.
D. C-section > 50%, mostly due to obstetric indications.
Regarding the fetal outcomes:2
A.Higher rates of pre-term delivery (40-50%); risk increases with maternal hypertension and serum creatinine > 1.7 mg/dl.
B. Higher incidence of fetal growth retardation (FGR); risk increases with maternal hypertension, proteinuria, and CNI use.
C. Increased incidence of low birth weight.
D. Spontaneous abortion is comparable to the general population with an incidence of 13-26 %; increased risk with MMf exposure.
E. Increased incidence of stillbirth compared to the non-transplant population.
However, sensitized patients could have a higher risk incidence 7.
This article is a systemic review and meta-analysis and provides level 1 of the evidence.
To determine outcome of pregnancy in kidney transplant recipients and its maternal and fetal complication, 87 studies with 6712 pregnancies in 4174 KT recipients were included.
Studied outcomes were as following:
1- Live birth rates higher compared to the US general population (72.9 % vs 62%)
2- Slightly lower rate of miscarriage (15.4 % vs general population but higher than Africa and south America.
3- Still birth rate was higher was higher than general population (5.1%vs 0.6%)
4- Slightly higher rate of ectopic pregnancy. (2.4% vs 1.4%)
5- Abortion rate was lower than the US general population (12.4%VS 1.4%)
6- Ectopic pregnancy was slightly higher than the US general population (2.4% vs 1.4%)
7- Preeclampsia was higher among kidney TX recipients (21.5%) than general population.
8- Rate of cesarean section among kidney recipients was 62.5 %(higher than general population).
9- Gestational diabetes among kidney TX recipients was 5-7 % which was lower than general population.
10- Pregnancy induced hypertension among kidney transplants recipients was 24.1 %
11- Preterm birth among kidney TX recipients was higher than general population (43.2%)
12- Neonatal mortality was higher than general population (3.8%)especially in Africa.
13- The acute rejection rate during pregnancy was 9.4% which was not different from the US mean of 9.1 %
14- The change in creatinine pre. and post pregnancy was statistically significant (1.23 VS 1.37)
15- The outcome considering neonatal deaths, C/S and live birth rate were less favorable in the patients who became pregnant in the interval of 2-3 years
Comparing with the > 3year, and < 2year interval (73% vs 65% vs 42%)
So, both maternal and fetal complication are common is kidney TX recipient s but totally favorable outcome especially regarding live birth rates were seen with preservation of the graft.
level of evidence: I ( a systematic review , metanalysis }
ESRD patients mainly have infertility and sexual problems ,this may be multi-factorial due to chronic inflammation ,uremia , medications, and hormonal factors . Post transplantation fertility and sexual desire improved .Complication occur in transplant patients during pregnancy ; spontaneous abortion in 15% stillbirths in 5 %, ectopic pregnancies in 2.4%, pre eclamptic toxemia in 21%, gestational diabetes in 5.7%, pregnancy induced hypertension in 24%, increased rate of elective cesarean section in 62% and preterm delivery in 43% . No need for elective C S because the graft does not causing any obstruction during normal labour .
fetal outcomes in renal transplant recipient are premature birth 43.1 % low birth weight, and small for gestational age infants .American guidelines recommended pregnancy after 1year post stable graft function {serum creatinine <1.5 mg/dl,and proteinuria <500 mg/24 h } while European guidelines recommend two year after kidney transplant .After 1year suitable graft function and there is no episode of rejection after discussion with nephrologist and counseling recipient about risk of pregnancy on graft function ,immunosuppression medication should be review . Pregnancy and outcome of the graft : Increase rate of acute rejection by ( 9.4 %) , and increase graft loss in the following 2 years (9.2 % ).
This is meta-analysis, observational study. Equivalent to level 1a.
Outcome presented by this study
Pregnancy outcome:
· Live birth rate 72.9%
· miscarriages rate 15.4%
· induced abortions rate 12.4%: lower than the US general population
· stillbirths rate 5.1%
· rate of ectopic pregnancies 2.4%: higher than the general population.
In this study cohort of kidney transplant recipients, live birth rates were higher and favorable across all geographic regions as compared to the US general population. Miscarriage rate was slightly lower than that of the US general population but higher in Africa and south America, while the rate of stillbirth is higher than the general population in USA, Asia and Africa.
Maternal outcomes
· rates of preeclampsia 21.5%
· cesarean section rate 62.6%
· rate of gestational diabetes 5.7%
· rate of pregnancy induced hypertension 24.1%
Fetal outcomes
· rate of pre-term birth 43.1%
· neonatal mortality was 3.8%
· The mean gestational age for newborns was 34.9weeks
· the mean birth weight was 2470 g (US mean, 3389 g).
Graft outcomes
· Acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% which was comparable to the US mean of 9.1%.
· Rate of graft loss was 9.2% among 489 recipients in 12 studies.
The level of evidence is I as its meta-analysis
Summary:
Pregnancy outcomes :
The live birth rate was 72.9%, abortions was 15.4%, stillbirth rate was 5.1% and ectopic pregnancy was 2.4 % .
Women outcomes :
increase rate of pre-eclampsia (21.5 % ) ,gestations DM (5.1 % ),pregnancy-induced Hypertension (24 % )and increase rate of CS .
Fetal outcomes:
Increase rate of preterm birth (43.1%) , low birth weights, and increase neonatal mortality.
Graft outcomes :
Increase rate of acute rejection ( 9.4 %) , an increase in creatinine level post-pregnancy in comparison to pre-pregnancy, and increase graft loss in the following 2 years (9.2 % ).
Level of evidence: I (as it is a systematic review and metanalysis)
Summary
Most of ESRD patients are infertile. However, recovery of hypothalamo-pit-gonadal axis was reported early after successful kidney transplantation in both males and females.
Pregnancy in kidney transplant recipients can be complicated by many issues as spontaneous abortion in 15%, induced abortions in 12 %, stillbirths in 5 %, ectopic pregnancies in 2.4%, pre eclamptic toxemia in 21%, gestational diabetes in 5.7%, pregnancy induced hypertension in 24%, increased rate of elective cesarean section in 62% and preterm delivery in 43% (1).
Hypertension is a common complication and was attributed to effect of steroids, CNI, original kidney disease and other personal factors as obesity and alcohol consumption. Gestational diabetes mostly related to steroid. CNI use in addition to ethnic and genetic predisposition to diabetes.
Increased rate of elective cesarean section should be discouraged as pelvic allograft does not obstruct the natural delivery through the birth canal (2, 3).
Hemolytic uremic syndrome (HUS), intrahepatic cholestasis, maternal hemorrhage and urinary obstruction were also documented in pregnancy after KT. Preeclampsia is defined as maternal hypertension and proteinuria combined with placental insufficiency and intra uterine growth retardation (4-7). it is a leading cause of fetal, early neonatal deaths and graft loss (8).
Poor fetal outcomes include premature birth (9, 10), low birth weight, and small for gestational age infants (2).
American Society of Transplantation recommends to delay conception for at least one-year post transplantation, whereas European best practice guidelines recommend at least 2 years to optimize the pregnancy and graft outcomes (11, 12). Such delay in pregnancy is a major problem especially in old mothers as age more than 35 years, with decreased ovarian reserve, will have lower fertility which represents a major psychological and relationship stress (13). psychological assessment and assurance plays a pivotal role in management of infertility in transplant recipients (14).
Pregnancy with pre-conception GFR of less than 40 ml/min/1.72 m2 was associated with poor graft and fetal outcomes (15). The graft loss may be attributed to hyper-filtration injury and progressive proteinuria (16, 17). Higher preconception GFR allows pregnancy to come to term and improve the neonatal outcomes (15).
References:
1. Shah S, Venkatesan RL, Gupta A, Sanghavi MK, Welge J, Johansen R, et al. Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review. 2019;20(1):1-22.
2. Bramham K, Nelson-Piercy C, Gao H, Pierce M, Bush N, Spark P, et al. Pregnancy in renal transplant recipients: a UK national cohort study. 2013;8(2):290-8.
3. Shah S, Verma PJIjon. Overview of pregnancy in renal transplant patients. 2016;2016.
4. Steegers EA, Von Dadelszen P, Duvekot JJ, Pijnenborg RJTL. Pre-eclampsia. 2010;376(9741):631-44.
5. Lisonkova S, Joseph KJAjoo, gynecology. Incidence of preeclampsia: risk factors and outcomes associated with early-versus late-onset disease. 2013;209(6):544. e1-. e12.
6. Mol BW, Roberts CT, Thangaratinam S, Magee LA, De Groot CJ, Hofmeyr GJJTL. Pre-eclampsia. 2016;387(10022):999-1011.
7. Wiles K, Chappell LC, Lightstone L, Bramham KJCJotASoN. Updates in Diagnosis and Management of Preeclampsia in Women with CKD. 2020;15(9):1371-80.
8. Majak GB, Sandven I, Lorentzen B, Vangen S, Reisæter AV, Henriksen T, et al. Pregnancy outcomes following maternal kidney transplantation: a national cohort study. 2016;95(10):1153-61.
9. Deshpande N, James N, Kucirka L, Boyarsky B, Garonzik‐Wang J, Montgomery R, et al. Pregnancy outcomes in kidney transplant recipients: a systematic review and meta‐analysis. 2011;11(11):2388-404.
10. Mohammadi F, Borg M, Gulyani A, McDonald S, Jesudason SJCt. Pregnancy outcomes and impact of pregnancy on graft function in women after kidney transplantation. 2017;31(10):e13089.
11. EBPG Expert Group on Renal Transplantation %J Nephrology D, Transplantation: Official Publication of the European Dialysis, Association TA-ER. European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV. 10. Pregnancy in renal transplant recipients. 2002;17:50-5.
12. McKay DB, Josephson MAJAjot. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. 2005;5(7):1592-9.
13. Szymusik I, Warzecha D, Wielgoś M, Pietrzak BJAot. Infertility in Female and Male Solid Organ Recipients–From Diagnosis to Treatment: An Up-To-Date Review of the Literature. 2020;25:e923592-1.
14. Olbrisch ME, Benedict SM, Ashe K, Levenson JLJJoc, psychology c. Psychological assessment and care of organ transplant patients. 2002;70(3):771.
15. Schwarz A, Schmitt R, Einecke G, Keller F, Bode U, Haller H, et al. Graft function and pregnancy outcomes after kidney transplantation. 2022;23(1):1-11.
16. Sun K, Lin D, Feng Q, Li F, Qi Y, Huang C, et al. Parity is associated with albuminuria and chronic kidney disease: a population-based study. 2019;11(23):11030.
17. Park S, Lee SM, Park JS, Hong J-S, Chin HJ, Na KY, et al. Midterm eGFR and adverse pregnancy outcomes: the clinical significance of gestational hyperfiltration. 2017;12(7):1048-56.
This is level 3 evidence.
Pregnancy is rare in dialysis women due to affected hypothalamic gonadal axis with conception rate from 0.9 to 7%.
After transplantation the fertility will improved within 6 months in some cases but conception is not without risk to the mother and the fetus.
Here is a meta analyses report according to PRISMA guidelines for studies explaining incidence and outcomes of pregnancy in kidney transplanted women.
1343 unique studies, 87 met inclusion criteria, representing 6712 pregnancies in 4173 kidney transplant recipients.
The mean maternal age was 29.6 – 24 years.
Pregnancy outcomes:
Live birth rate was 72.9%
Miscarriage 15.4%
Induced abortion 12.4%
Still birth 5.1%
Ectopic pregnancies 2.4%
Maternal outcomes:
Preeclampsia 21.5%
Cesarean section 62.6%
Pregnancy induced hypertension 24.1%
Fetal outcomes:
Preterm birth 43.1%
Neonatal mortality 3.8%
Graft outcomes:
Acute rejection 9.4%
Time of conception:
It was found that more adverse effect to the mother and the fetus in 2 – 3 years following transplantation as compared to 3 years.
In conclusion this meta-analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients.
Data was collected over several decades all over the world showing favorable outcomes in live birth rates higher than normal population but high risk of maternal and fetal adverse effect that signify proper counseling and planning.
.
1- What is the level of evidence of this study?
This study is a meta analysis – level 1 .
2- Summarise the pregnancy outcome presented by this study
Introduction
Women with ESRD get infertility due to defect of hypothalamic gonadal axis.Gestation is rare in women on dialysis ( 0.9 to 7%).
Kidney transplantation provide best chance for pregnancy as fertility is restored within 6 month post transplantation .
Inspite of this Pregnancy in a kidney transplant recipient continues has it own fetal and maternal complication such as
1. preeclampsia
2. hypertension,
3. premature birth,
4. low birth weight,
5. small for gestational age infants
6. side effects from immunosuppressive medication,
7. Risk of deterioration of allograft function .
Therefore, preconception counseling , family planning and contraception are pertinent parts of the transplant counseling process.
Pregnancy outcome :
. Rates of preeclampsia, still birth, and cesarean section were significantly higher than in the general population.
In one study , a quarter of women had serious pregnancy complications .and the rates of preterm delivery, still births, and neonatal mortality were higher as compared with the US recent national data.
The live birth rates in women after kidney transplant were higher than in the general population (73% vs. 62%) .
In contrast to these findings of successful pregnancies, in one a US study found a much lower live birth rate of 55% in kidney transplant recipients.
This study demonstrate the high maternal and fetal complications in women with kidney transplants. About one fourth of women developed preeclampsia, and the rates of preeclampsia were six times higher as compared to the general US population.
In a study by Vannevel et al. showed a preeclampsia rate of as high as 38%, and chronic hypertension rate of 27% .
The stillbirth and neonatal mortality rate were higher in this study as compared to the general
population.
This study, the cesarean section rate was two times higher as compared to general population in United States .
Vaginal deliveryshould not be neglected in transplant women , as the pelvic allograft does not obstruct the birth canal in most patients .
The best time to pregnancy after transplantation remains grey zone.
American Society of Transplantation recommend the ideal time on pregnancy of 1-2 years after transplantation , while European best practice guidelines recommend a gestation after 2 year from transplantation.
In this study, live birth rate was lowest and neonatal deaths were highest in the 2–3 year interval following kidney transplant.
Maternal complication of cesarean section and preeclampsia were higher in the 2–3 and>3year interval. Contrary to this finding , Deshpande et al. reported both the highest maternal complications of preeclampsia, cesarean section, and gestational diabetes, and least favorable delivery outcome of preterm births in the < 2 year interval as compared to > 2 year interval between kidney transplant and pregnancy.
This is a secundar study. Metaanalysis and systematic review are level 1.
The pregnancy outcomes included:
– Number of live births: Live birth rate was 72.9% (95% CI, 70.0–75.6). It was higher as compared to the US general population (72.9% vs. 62%) and favorable across all geographic regions. There are inconsistencies in definition of live birth rate used in various studies, but It´s possible that what is more important is that the numbers may reflect a reporting bias or a selection bias in which relatively healthy women decided to pursue pregnancy, and subsequently received better medical support by multiple specialties.
– Miscarriage: rate was 15.4% (95% CI, 13.8–17.2). It was slightly lower than that of the US general population (15.4% vs. 17.1%), but higher across Africa (21.0%), and South America (20.2%);
– Induced abortion: rate was 12.4% (95% CI, 10.4–14.7). It was also lower than the US general population (12.4% vs. 18.6%), was highest in South America (19.8%), followed by Asia (13.3%;), Oceania (11.5%;), North America (10.9%;), Europe (10.0%; ), and Africa (7.7%)
– Still birth: rate was 5.1% (95% CI, 4.0–6.5) . It was higher than the US general population (5.1% vs. 0.6%). Worldwide, stillbirth rate was highest in Asia (6.6%), and lowest in Africa (2.6%)
-Ectopic pregnancies: rate of ectopic pregnancies was 2.4% (95% CI, 1.5–3.7). It was slightly higher than the US general population (2.4% vs. 1.4%), with highest rate in Asia (3.3%)
A] What is the level of evidence of this study?
B] Summarise the pregnancy outcome presented by this study
The incidence of pregnancy in women on dialysis is low 0.9-7% due to disruption in hypothalamic gonadal axis, however fertility post transplantation restore within 6 months * the occurrence of adverse maternal complication , pre-eclampsia , hypertension feral complication ( low birthweight, small forgestional birth weight) cha make pregnancy
Challenge for transplant recipient.
So family planning considered important corner in transplantation program.
* this meta- analysis shown as below:-
– induced abortion rate less than us general population( 5.1, 0.6%) respectively.
– miscarriage is little lower than us general population ( 15.4, 17.1% ) respectively.
– live birth higher than us general population( 5.1, 0.6% ) respectively
– pre-eclampsia 12.4%
– gestational dm 5.7%.
– neonatal mortality 3.8%
Conclusions…
pregnancies in 4174 kidney transplant recipients with data spread over different decades from all over the world shows favorable outcomes with live birth rates exceeding that in the recent national population. Majority of patients preserve their graft. However,
pregnancy after renal transplant confers significant risk in terms of maternal and fetal adverse events, in- cluding increased rates of preeclampsia, gestational diabetes, cesarean section rates, and pregnancy in- duced hypertension. The risk of prematurity and low birth rate are also high. Areas which need to be studied in the future include type of immunosuppression and its cor- relation with specific pregnancy outcomes; and evaluation of risk factors associated with specific maternal and fetal adverse events. The definitions used in evaluating these outcomes also need to be standardized. The results of this study can help the health care providers with appropriate counseling and individualized management of this high risk population.
References
1. Shah S, Verma P. Overview of pregnancy in renal transplant patients. International journal of nephrology. 2016;2016:4539342.
2. Saha MT, Saha HH, Niskanen LK, Salmela KT, Pasternack AI. Time course of serum prolactin and sex hormones following successful renal transplantation. Nephron. 2002;92(3):735–7.
3. Bramham K, Nelson-Piercy C, Gao H, Pierce M, Bush N, Spark P, Brocklehurst P, Kurinczuk JJ, Knight M. Pregnancy in renal transplant recipients: a UK national cohort study. Clin J Am Soc Nephrol : CJASN. 2013;8(2):290–8.
4. Sifontis NM, Coscia LA, Constantinescu S, Lavelanet AF, Moritz MJ, Armenti VT. Pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolate mofetil or sirolimus. Transplantation. 2006;82(12):1698–702.
5. Davison JM, Redman CW. Pregnancy post-transplant: the establishment of a UK registry. Br J Obstet Gynaecol. 1997;104(10):1106–7.
Level of evidence I
Level of the evidence is level I
Maternal outcomes
rates of : – preeclampsia was 21.5%
– cesarean section was 62.6%
– gestational diabetes was 5.7%
– pregnancy induced hypertension was 24.1%
Fetal outcomes
– preterm birth (babies born alive before 37 weeks of gestation) was 43.1%
– neonatal mortality was 3.8%
Graft outcomes
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%.
The time of conception is an important determinant of the outcome
Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to < 2 year interval and > 3 year interval (16% vs. 11% vs. 10, and 9% vs. 3% vs. 4% respectively).
Maternal age for conception has an impact on the outcomes:
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs.76%). Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
It is meta analysis study with level I evidence.
In this study we can conclude that kidney transplantation carries higher risk for both fetal and maternal side effects such as higher rate of preeclampsia,gestational diabetes and hypertension,cesarean section rate and other complications all are significantly higher in kidney recipient women compared to normal population.
Pregnancy outcomes
– live birth has a higher rate compared to US and it’s rate was 72.9% and miscarriage rate is lower than US with a rate of 15.7%
– ectopic pregnancy rate was 2.4% while still birth rate was 5.1%
– induced abortion rate was 12.4%
Maternal outcomes:-
-Pre eclampsia rate was 21.5%
-cesarean section rate was 62.6%
-gestetional diabetes was 5.7%
-pregnancy induced hypertension was 24.1%
Fetal outcomes
– preterm birth was 43.1%
– neonatal mortality was 3.8%
Graft outcome
– overall acute rejection in pregnant women having kidney transplant during pregnancy was 9.4% while graft loss post pregnancy by years was 9.2 %
This meta-analysis included a total of 87 studies, involving 6712 pregnancies in 4127 kidney transplant recipients. The pregnancy outcomes are as follows:
1) Higher rates of live births than the general population, with half of them having preterm delivery. Women in the age group 29-34 years showed lower live birth rates.
2) 25 % pts have stillbirths and ectopic pregnancies than the general population.
3) Lower rates of miscarriages and induced abortions seen in transplant recipients.
4) Rates of preeclampsia were 6 times higher than the general population
5) Rates of Cesarean sections were 2 times the general population.
6) Gestational diabetes mellitus was less common in the transplant recipients.
7) Pregnancy induced hypertension was seen in one fourth of the transplant recipients.
8) Approximately 10 times higher neonatal mortality was seen in the transplant recipients.
9) Among the transplant recipients. the mean birth weight was less than 2500 grams and mean gestational age for newborns was 34.9 weeks.
10) Acute rejection rates were comparable to the non-pregnant transplant recipients.
11) Time of conception decides about pregnancy outcomes with lowest live birth rates and highest neonatal deaths seen among pregnancies in 2-3 year interval post-transplant.
12) Fetal outcomes were better in pregnancies within 2 years post-transplant, but could be a manifestation of reporting bias.
Overall, the rates of maternal and fetal complications were higher in the transplant recipients, but having a better outcome than general population with preservation of graft function.
Level 1 evidence
WHAT IS THE LEVEL OF EVIDENCE OF THIS STUDY?
level I
SUMMARISE THE PREGNANCY OUTCOME PRESENTED BY THIS STUDY
women who undergoing dialysis found to have low incidence of conception (0.9 to 7%), due to disruption of the hypothalamic gonadal axis. Transplantation considered the best way for women who undergoing dialysis wished to become pregnant. Pregnancy in a KTR is challenging due to:
Preconception counselling, family planning, and contraception are pertinent parts of the transplant counselling
The primary objective of this study was to perform a meta-analysis to systematically identify all studies of pregnancy-related outcomes in kidney transplant recipients around the world and estimate pooled incidence of pregnancy outcomes, maternal complications, and foetal complications. The secondary outcome was to examine the impact of pregnancy on the kidney allograft loss, and allograft rejection, identify the ideal maternal age of conception and determine the ideal time of conception between kidney transplant and pregnancy
The study demonstrated
Foetal outcomes
Graft outcomes
Level of evidence I
Pregnancy outcomes
live birth rates were higher as compared to the US general population
miscarriage rate was slightly lower than that of the US general population
Induced abortion rate was also lower than the US general population
stillbirth rate was higher than the US general population
The rate of ectopic pregnancy was slightly higher than the US general population
Maternal outcomes:
rates of preeclampsia was 21.5%
cesarean section was 62.6%
gestational diabetes was 5.7%
pregnancy induced hypertension was 24.1%
Fetal outcomes
rate of preterm birth was 43.1%
neonatal mortality was 3.8%
The mean gestational age for newborns was 34.9weeks
the mean birth weight was 2470 g
Neonatal mortality was high across all geographical regions as compared to the US mean
Graft outcomes
The overall acute rejection rate during pregnancy was 9.4%
With regards to graft failure, there was large variability in the follow up period ranging from 1 year to 14 years. However among 489 recipients in 12 studies where two-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%)
Time of conception
Outcomes were stratified by interval of 3 years between pregnancy and kidney transplant
Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3year interval following kidney transplant as compared to 3 year interval .Cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years than > 3 year, and 3 year
interval than 3 years interval followed by 2-3 years interval, and <2 years interval.
Maternal age for conception
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years .Rates of spontaneous abortion were highest in women 35 years followed by women with maternal age 25–34years .Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review
This is a systemic review and meta analysis on the pregnancy outcome in women with renal transplant with level 1 evidence. This review study the associations of maternal age, the interval between kidney transplant, and the pregnancy outcomes. Subgroup analysis included maternal and fetal outcomes for studies published from 2000 to 2017. There were 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years. For the pregnancy outcomes Live birth rate was 72.9% miscarriages rate was 15.4% , induced abortions rate was 12.4% , stillbirths rate was 5.1% and rate of ectopic pregnancies was 2.4% . For maternal outcomes, the rates of preeclampsia was 21.5%, cesarean section was 62.6%, gestational diabetes was 5.7%, and pregnancy induced hypertension was 24.1%. For fetal outcomes, the rate of preterm birth was 43.1% and neonatal mortality was 3.8%. For graft outcomes, acute renal allograft rejection were highest in Asia (11.0%), followed by South America (10.7%), Oceania (9.1%), Europe (7.3%), North America(6.7%), and Africa (4.8%). Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant, cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years. On the other hand, maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year (24% vs. 23% ). Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and<2 interval (16% vs. 14% vs. 10%).Lower live birth rate was observed in women with maternal age 29–34 years. Rates of spontaneous abortion were highest in women < 25 years (20%) and > 35 years (18%) . Preeclampsia rates were higher in women with maternal age > 35 years (27%). This systemic revealed significantly higher risk of maternal and fetal complications in women with kidney transplants. Hypertension, gestation diabetes are the common risk factor among transplant recipients before conception which lead to high rates of stillbirth and neonatal mortality due to premature delivery. The rate of cesarean section was high might be attributed to fetal and maternal complications. The ideal time of conception in women with renal transplant is between 1 and 2 years after transplantation. The limitation of this systemic review include inconsistencies in the definition of live birth rate amongst different studies. Reporting bias may have affected the miscarriage rate. Unable to account for differences in socioeconomics, and healthcare conditions among the different geographic regions. No data for pregnancy outcomes in relation to immunosuppression regimens. The strength of this systemic review include large number of pregnant renal transplant recipients from all around the globe, thus providing us with information about pregnancy outcomes for a heterogeneous population. In conclusion, renal transplant confer risks for both mother and fetal adverse outcome. Future research should focus on type of immunosuppression and its correlation with specific pregnancy outcomes; and evaluation of risk factors associated with specific maternal and fetal adverse events.
What is the level of evidence of this study?
This meta-analysis So the level of evidence is 1
ESRD affects the reproductive system due to Disturbed hypothalamic-pituitary gonadal axis leads to hormonal profile problems , loss of libido.
After renal transplant fertility improves in a few weeks and full restorations may happen as early as 6 months , so Contraception should be planned prior to transplantation to minimize the risks, optimal conditions for a pregnancy when desired, and to suggest What is the safety profile of immunosuppressive therapy in pregnancy & lactation and Planning contraception.
Maternal outcome :
cesarean section was 62.6%
rates of preeclampsia was 21.5%
pregnancy induced hypertension was 24.1%
gestational diabetes was 5.7%
Fetal outcomes
rate of preterm birth was 43.1%
The mean gestational age for newborns was 34.9weeks
the mean birth weight was 2470 g
Graft outcomes
The overall acute rejection rate during pregnancy was 9.4%
With regards to graft failure, there was large variability in the follow up period ranging from 1 year to 14 years. However among 489 recipients in 12 studies where two-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%)
Time of conception.
Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3year interval following kidney transplant as compared to 3 year interval.
Level of evidence I meta-analysis.
1. Level 1 evidence
2. Summary: Pregnancy in a kidney transplant recipient continues to remain challenging due to risk of adverse maternal complications as well as the risk of adverse fetal outcomes. Additionally, there is risk of side effects from immunosuppressive medication, and risk of deterioration of allograft function.
In this analysis t, Shah, S. et al, reported a higher rates of preeclampsia 21.5% (depending on geographical distribution), a higher cesarean section rates of 62.6%, gestational diabetes was 5.7% and pregnancy induced hypertension was 24.1%. The rate of other pregnancy outcomes was as follows: induced abortions (12.4%; 95% CI, 10.4–14.7), miscarriages (15.4%; 95% CI, 13.8–17.2), stillbirths (5.1%; 95% CI, 4.0–6.5), ectopic pregnancies (2.4%; 95% CI, 1.5–3.7), preeclampsia (21.5%; 95% CI, 18.5–24.9), gestational diabetes (5.7%; 95% CI, 3.7–8.9), pregnancy induced hypertension (24.1%; 95% CI, 18.1–31.5), cesarean section (62.6, 95% CI 57.6–67.3), and preterm delivery was 43.1% (95% CI, 38.7–47.6). The rate of spontaneous abortion was higher in women with mean maternal age < 25 years and > 35 years as compared to women aged 25–34 years.
The risk of adverse fetal outcomes of premature birth, low birth weight, and small for gestational age infants remained high. The live-birth rate was 72.9% (95% CI, 70.0–75.6). The rate of preterm birth was 43.1% (95% CI, 38.7–47.6) defined by babies born alive before 37 weeks of gestation, and neonatal mortality was high across all geographical regions was 3.8% (95% CI, 2.8–5.2).
The 2–3-year interval following kidney transplant had Maternal complication of preeclampsia and higher neonatal mortality, and lower rates of live births as compared to > 3 year, and < 2-year interval.
Overall, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making.
Level of evidence : Meta-analysis , level 1
outcomes summary :
Live birth rate was 72.9% ( higher than general population ) , miscarriages rate was 15.4% ( lower than general population in USA but higher in Africa & South America ) , induced abortions rate was 12.4% , stillbirths rate was 5.1% (higher than the US general population (5.1% vs. 0.6%) . Worldwide, stillbirth rate was highest in Asia , and lowest in Africa ) and rate of ectopic pregnancies was 2.4% .
– Preeclampsia & Pregnancy-induced hypertension were higher than general population (21.5% & 24.1 respectively )
–Cesarean section was 62.6% ( high )
-Gestational diabetes was 5.7%.
The rate of preterm birth was 43.1% ( live birth before 37 weeks of gestation)
neonatal mortality was 3.8%
The overall acute rejection rate during pregnancy 9.4% which is comparable to the general population )
Conclusions:
This meta analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients with data spread over different decades from all over the world shows favorable outcomes with live birth rates exceeding that in the recent national population. Majority of patients preserve their graft. However, pregnancy after renal transplant confers significant risk in terms of maternal and fetal adverse events, including increased rates of preeclampsia, gestational diabetes, cesarean section rates, and pregnancy induced hypertension. The risk of prematurity and low birth rate are also high.
Its a meta analysis to assess the outcome of pregnancy in kidney transplant patients.
Infertility is usually improving and most post transplant patients will regain there fertility within few months ,due to restoration of normal hypothalamic, pituitary adrenal axis. function. Nevertheless , pregnancy post transplantation is not as safe as its in normal pregnancy. with multiple maternal ,fetal and allograft comorbidities challenging the outcome.
This meta analysis study performed to address this issue .
pregnancy outcomes as shown by the study:
1] Majority of post transplant pregnancies result in life birth.
2] In the Cohort considered for analysis,25% of them had serious pregnancy related complications
3]The live birth rate in post transplant pregnancies is higher than the general population rate ,a finding that might reflect a reporting bias or a selection bias as in which only healthy kidney transplant women pursue pregnancy;
4] 25% higher rate of pre eclampsia, 6 times higher rate than general population.
5]Hypertension is a common finding in transplant patients and higher post transplantation 50-60%. Transplantation related factors that induced hypertension include, immunosuppressants {CNi and CS}, donor type, obesity, alcohol, smoking, allograft function , and presence of native kidney{due to Renin over production}.
6] higher rate of Diabetes Mellitus ,however with variable rates in different geographical regions, from 1% to 8.9%, Which is obviously linked to CNi and Cs and importantly influenced by ethnicity.
7] Stillbirth and neonatal mortality are higher than the rate in general population, it could be related to higher incidence of pre eclampsia , proteinuria, hypertension allograft dysfunction with creatinine of more than 1.5 mg/dl.
8] The rate of cesarean section is double the rate in general population. ranging between 60 to 77 %, attributed to fetal and maternal complications.
9] Premature delivery reported in 50 % of live birth ,attributed to pre eclampsia, fetal complications and renal compromise are main indications for premature delivary.
10]maternal and fetal complication were higher in pregnancies during the first 2 years post transplantations.
the study is meta analysis with level of evidence 1
Reproductive system function in women with end stage renal disease is decreased due to Disturbed hypothalamic-pituitary gonadal axis, disturbed hormonal profile (H prolactin, H FSH, H LH, lack of LH surge, L estradiol, L progesterone) Infertility- anovulation- menstrual irregularities- loss of libido.
It all start to improve in a few weeks after renal transplantation & full restorations may happen as early as 6 months. However, pregnancy remains challenging due to the risk of adverse clinical outcomes. on mother, fetous as well as in the graft.
Contraception should be planned prior to transplantation to minimize the risks, optimal conditions for a pregnancy when desired, and to suggest What is the safety profile of immunosuppressive therapy in pregnancy & lactation and Planning contraception.
Despite that live birth rates are comparable to the general population, pregnancy rate is lower and is noted to decline over the years. Likely related to, introduction of MMF, Improved contraceptive counselling, longer waiting time on the transplant list and older maternal age at transplantation. cohort (Fig. 1).
Three studies were from Africa, 31 from Asia, 31 from Europe, 10 from North America, 4 from Oceania, and 8 from South America. Overall, there were 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years.
What is the level of evidence of this study?
This meta-analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients with data spread over different decades from all over the world.
So the level of evidence is 1
Summarize the pregnancy outcome presented by this study?
Pregnancy outcomes:
– Live birth rate was 72.9% higher as compared to the US general population and favorable across all geographic regions
– miscarriages rate was 15.4%, higher across Africa and South America.
-induced abortions rate was 12.4% highest in South America, followed by Asia, Oceania, North America, Europe, and Africa
stillbirths rate was 5.1 was highest in Asia and lowest in Africa
Ectopic pregnancies were 2.4 with highest rate in Asia
Maternal outcomes
– preeclampsia, rates were 21.5 highest in Oceania, followed by North America and lowest in Africa
-Cesarean section was 62.6% was highest in South America, followed by Africa
-Gestational diabetes was 5.7%, Oceania had the lowest rates.
pregnancy induced hypertension was 24.1% highest in South America while lowest in Africa.
Fetal outcomes:
– Preterm birth was 43.1% defined by babies born alive before 37 weeks of gestation, being highest in South America and lowest in North America.
-Neonatal mortality was 3.8% with the highest rate being in Africa and lowest rate in North America.
The mean gestational age for newborns was 34.9 weeks and the mean birth weight was 2470 g.
Graft outcomes.
Acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% was highest in Asia , followed by South America.
Graft failure among 489 recipients in 12 studies where two-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%).
Time of conception.
Abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to < 2 year interval and > 3 year interval .
Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year interval than < 2 year interval.
Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and < 2 interval.
Maternal age for conception.
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years.
Spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years.
Preeclampsia rates were higher in women with maternal age > 35 years and 29–34 years followed by < 25 years and 25–29 years.
Conclusion: Although the outcome of live births is favorable, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making
Level of evidence 1.
Kidney transplantation offers the best hope to women with end-stage renal disease who
wish to become pregnant.
Pregnancy outcomes:
Live birth rate was 72.9%. Favorable across all geographic regions.
Miscarriages rate was 15.4%. Higher across Africa 21%, and South America 20.2%.
Induced abortions rate was 12.4% , The rate of induced abortion was highest in South
America 19.8%; followed by Asia 13.3%, Oceania11.5%, North America 10.9%; , Europe
10.0%; , and Africa 7.7%
Stillbirth’s rate was 5.1%.
Stillbirth rate was highest in Asia 6.6%, and lowest in Africa 2.6%,
Ectopic pregnancies was 2.4%.
With highest rate in Asia 3.3%.
Maternal outcomes:
Overall, rates of preeclampsia was 21.5% .
Cesarean section was 62.6%
Gestational diabetes was 5.7% .
Pregnancy induced hypertension was 24.1%.
Preeclampsia rate was highest in Oceania 27.0%, followed by North America 25.5%;
and lowest in Africa 10.5%. Cesarean section rate was highest in South America,
followed by Africa 77%.
Worldwide, Oceania had the lowest rates of gestational diabetes 1.0%.
With regards to pregnancy induced hypertension, highest rate was reported in South
America 48.0%,
While lowest rate was in Africa 16.1%.
Fetal outcomes:
Rate of preterm birth was 43.1%, and neonatal mortality was 3.8%.
Rates of preterm birth was highest in South America 55.0%, and lowest in North America
35.4%, the mean gestational age for newborns was 34.9 weeks.
Mean birth weight was 2470 g.
Neonatal mortality was high across all geographical regions as compared to the US
mean (3.8% vs. 0.4%), with highest rate in Africa 18.4% and lowest rate in North
America 1.3%.
Graft outcomes:
Acute rejection rate during pregnancy was 9.4%, which was comparable to the US
mean of 9.1%. Rates of acute renal allograft rejection were highest in Asia (11.0%),
followed by South America (10.7%), Oceania (9.1%), Europe (7.3%), north America
(6.7%), and Africa (4.8%).
Time of conception:
Stratified by interval of < 2 years, 2–3 years, and > 3 years between pregnancy and
kidney transplant .
Induced abortion rates and neonatal deaths were highest in the 2–3 year interval
following kidney transplant as compared to < 2 year interval and > 3 year interval.
Cesarean section rate and live birth rate were also less favorable in this interval of 2–3
years than > 3 year, and < 2 year interval.
Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year
interval than < 2 year interval .Spontaneous abortion rates were highest in > 3 year
interval followed by 2–3.
Maternal age for conception:
Lower live birth rate was observed in women with maternal age 29–34 years than those
< 29 years (74% vs. 76 %.).
Rates of spontaneous abortion were highest in women < 25 years and > 35 years
followed by women with maternal age 25–34 years.
Preeclampsia rates were higher in women with maternal age > 35 years 27%.
-level of evidence 1
-Shortly after transplantation fertility could be regained (within 6 month), so ideally speaking pregnancy must be planned rather than contraindicated.
A meta-analysis was performed to track pregnancy-related maternal and fetal outcomes worldwide and address their incidence as a primary outcome.
It included 6712 pregnancies in 4174 transplant recipients encountered in 87 studies
Revealed
pregnancy outcome
1- Successful pregnancy rate was 72.9%*
*This rate is more than the general population 62% may be due to that these pregnant women receive better care from different specialities, the difference in data reporting he’s rate either per 1000 or per 100000 pregnant women, or due to the exclusion of recipient received MMF and other teratogenic drugs from studies
2- miscarriages rate was 15.4%
3- induced abortions rate was 12.4%
4- stillbirths rate was 5.1%
5- ectopic pregnancies was 2.4%
Maternal outcomes
1- preeclampsia was 21.5%
2- cesarean section was 62.6% – highest in South America
3- gestational diabetes was
4- Pregnancy-induced hypertension was 24.1%
Fetal outcomes
1- preterm birth (before 37 weeks) was 43.1%
2- neonatal mortality was 3.8%
3- Mean gestational age for newborns was 34.9 weeks
Graft outcomes
1- Acute rejection rate 9.4%
2- two-year post pregnancy graft loss was reported among 489 recipients in 12 studies where s to be (9.2%).
What is the level of evidence of this study?
level of evidence of 1
Summarise the pregnancy outcome presented by this study
pregnancy outcomes
Live birth rate was 72.9%.
miscarriages rate was 15.4%.
induced abortions rate was 12.4%
stillbirths rate was 5.1%
ectopic pregnancies was 2.4% (95% CI, 1.5–3.7).
Maternal outcomes :
rates of preeclampsia was 21.5%.
cesarean section was 62.6%
gestational diabetes was 5.7%.
pregnancy induced hypertension was 24.1% .
Graft outcomes
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%.
Time of conception Outcomes were also stratified by interval of < 2 years, 2–3 years, and > 3 years between pregnancy and kidney transplant.
induced abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to < 2 year interval and > 3 year interval (16% vs. 11% vs. 10, and 9% vs. 3% vs. 4% respectively).
Cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years than > 3 year, and < 2 year interval (68% vs. 75% vs. 74, and 73% vs. 65% vs. 42% respectively).
Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year interval than < 2 year interval (24% vs. 23% vs. 13%).
Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and < 2 interval (16% vs. 14% vs. 10%).
Maternal age for conception
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs. 76%).
Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
This is a meta-analysis with level evidence of I
In this meta-analysis evaluating 6712 pregnancies (4174 women) live birth was 72.9 %, miscarriage 15.4%, stillbirths 5.1%, and ectopic pregnancy 2.4%. these percentages varied with respect to rates of the general population according to the place of follow-up.
In terms of maternal outcomes associated with pregnancies, the overall preeclampsia rate was 21.5%. C/S was performed in 62 % of cases.
In 822 kidney transplant recipients evaluated, the acute rejection rate during pregnancy was 9.4%. post-delivery follow-up varied among studies but 489 recipients (from 12 studies) were evaluated and 32 cases (9.2%) were reported. Follow-ups varied from 1 to 14 years.
In sum, the rate of stillbirth, preeclampsia and C/s was higher than the general population. gestational diabetes, as well as rejections, were not well evaluated because of individualizing of treatments.
Pregnancy outcomes in women with kidney transplant: Metaanalysis and systematic review.
Level of evidence is 1.
Summary of pregnancy outcomes:
This meta-analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients shows favorable outcomes with live birth rates and majority of patients preserve their graft.
However, pregnancy after renal transplant has significant risks of maternal and fetal adverse events, including increased rates of preeclampsia, gestational diabetes, cesarean section rates, and pregnancy induced hypertension. The risk of prematurity and low birth rate are also high.
Pregnancy outcomes:
Kidney transplant recipients, live birth rates were higher as compared to the US general population (72.9% vs.62%).
Miscarriage rate was slightly lower than that of the US general population (15.4% vs. 17.1%). But higher across Africa and South America.
Induced abortion rate was also lower than the US general population (12.4% vs. 18.6%).Being highest in South America, followed by Asia, Oceania, North America, Europe and Africa.
Stillbirth rate was higher than the US general population (5.1% vs. 0.6%).Worldwide, stillbirth rate was highest in Asia and lowest in Africa.
The rate of ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%), with highest rate in Asia.
Maternal outcomes:
Rates of preeclampsia was 21.5%, cesarean section was 62.6%, gestational diabetes was
5.7%, and pregnancy induced hypertension was 24.1%.
Preeclampsia rate was highest in Oceania, followed by North America, and lowest in Africa.
Cesarean section rate was highest in South America followed by Africa.
Oceania had the lowest rates of gestational diabetes.
Pregnancy induced hypertension, highest rate was reported in South America, while lowest rate was in Africa.
Fetal outcomes:
Rate of preterm birth was 43.1% being highest in South America and lowest in North America.
Neonatal mortality was high across all geographical regions with highest rate in Africa and lowest rate in North America.
Graft outcomes:
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%.
Rates of acute renal allograft rejection were highest in Asia (11.0%), followed by South America
(10.7%), Oceania (9.1%), Europe (7.3%), North America (6.7%), and Africa (4.8%).
There were 32 cases of graft loss (9.2%) were reported.
The change in preconception creatinine and post-pregnancy creatinine, was statistically significant (1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007).
Maternal age for conception:
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs.76%).
Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review
What is the level of evidence of this study?
level 1 of evidence (Metanalysis and systematic review)
Summarize the pregnancy outcome presented by this study
ABSTRUCT:
Male and female Fertility fully recovered early post-transplant period in the first 1-6 months .Pregnancy post-transplant still encouraged with more medical and surgical challenges that affect the mother, fetus and the graft .Proper counselling should be done at time of transplant work up addressing all the potential medical and surgical risk to the mother ,fetus and the kidney graft and avoid unplanned pregnancy especially in the first two years after transplant due to high risk of infections , rejection , intense immunosuppression with its associated maternal and fetal risks including hypertension , proteinuria preeclampsia , UTI including pyelonephritis , rejection , CNI toxicity
AIM
Comprehensive metanalysis and systematic review of the all-registered retrospective studies or case series based, observational studies of pregnancy outcome in kidney transplant recipients, worldwide and assess the incidence of pregnancy post-transplant and The secondary outcome were examine the effect of pregnancy on the kidney allograft loss, allograft rejection, identify ideal motherly age of conception, and determine ideal time of conception between kidney transplant and pregnancy
Method: review of the available studies of pregnancy in kidney transplant from PubMed Cochrane database, midline and embase, Elsevier Scopus, Expanded, citation-index from 2000-2017
Exclusion criteria include non-English studies, studies with overlap cohort results, multiple organ transplant, case series with < 10 cases, double records
Data extraction and analysis by three independent data-extraction teams with double check and analysis of the data
Results:
87 studies match with inclusion criteria of more than 6712 pregnancy in > 4600 recipients with mean maternal age of 29, with live birth rate > 72 %, and miscarriage rate 15.4%, abortion 12.4 %, stillbirth 5.1%, ectopic pregnancy 2.4%, preeclampsia rate 21%, pregnancy induced hypertension 24%, GDM 5.7%, CS rate higher in kidney transplant reached up to 62%, premature birth preterm > 40% with mean gestational age of 34 weeks and low birth wt with mean of 2450 with higher neonatal mortality in 2-3 years post transplantation
Maternal outcome
1-Over all pregnancy post-transplant associated with higher rate of preeclampsia, GDM, PIH, CS, proteinuria.
2-Cesarean section rate was highest in South America (88.8%) followed by Africa (77.5).
3- pregnancy induced hypertension (PIH) highest rate was in South America (48.0% while
lowest rate was in Africa (16.1%)
4- Oceania had the lowest rates of gestational diabetes (1.0%) but higher rate of preeclampsia
(27.0%).
Fetal outcome
1-favorable outcomes with live birth rates above that in the recent national population
2-fetal preterm birth was 43.1% highest in south America > 55% and lowest in north America 38%
3-Neonatal mortality was high across all geographical regions as compared to the US mean (3.8% vs. 0.4%).
4-The risk of prematurity and low birth rate are also high. Which need more studies including the type of immunosuppression and its correlation with specific pregnancy outcomes.
Graft outcome
Majority of patients preserve their graft function with overall lower rate of rejection around 9% however higher rate of rejection found in specific ethnic back ground like Asia 11% followed by south America 10.7 while in Europe 7.2 %, Africa even lower 4.8 %.
Maternal age for conception:
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs.76%)
Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women
with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal
age > 35 years (27%) and 29–34 years (26%) followed by
< 25 years (17%) and 25–29 years (14%)
Time of conception:
the best time for conceptions’ between 1-2 years , not 2-3 years or more than 3 years as the rate of fetal loss and neonatal death higher.
Strength of the study
1- Large sample size reflects the pregnancy outcome from different populations
2-Address Region specific pregnancy related outcome
3-Identify the pregnancy outcome in specific risk group both will allow to generate specific recommendation for such specific region and risk group to be followed
Limitation of the study
1-Assessing the pregnancy outcome from data spread over different decades.
2-limitation of the retrospective study design, small numbers, and likely reporting bias associated with data from intended registries.
3-unable to account for differences in socioeconomics, and healthcare conditions among the different geographic regions. Due to lack of individual patient data,
4-unable to assess pregnancy outcomes in relation to immunosuppression regimens.
Meta-analysis and systematic review ;Level I
This review included 87 studies, over a long-time frame (from 2000 to 2017), including 6712 pregnancies in 4127 kidney transplant recipients. The outcomes were as follows:
* Higher rates of live births than general population, 50% having preterm delivery. Lower live birth rates in women in the age group 29-34 years and spontaneous abortions were least in the 25-34 years aged women.
* About 25% had serious complications related to pregnancy with higher rates of stillbirths and ectopic pregnancies compared with general population
* Lower rates of miscarriages and induced abortions .
* Preeclampsia was 6 times higher compared with general population
* Cesarean sections were twice the general population
* Gestational diabetes mellitus was less common in the transplant recipients.
* Pregnancy induced hypertension was seen 25% of the transplant recipients.
*Approximately 10 times higher neonatal mortality shown in transplant recipients.
* Mean birth weight was less than 2500 grams and mean gestational age for newborns was 34.9 weeks in transplant recipients.
*Acute rejection rates were similar to the non-pregnant transplant recipients.
*Time of conception had impact on pregnancy outcomes; with lowest live birth rates and highest neonatal deaths seen among pregnancies in 2-3 year interval post-transplant. CS and preeclampsia were higher after 2 year interval.
* Fetal outcomes were found better in pregnancies within 2 years post-transplant, but could be biased by reporting.
* Graft function was preserved in majority of patients.
.
What is the level of evidence of this study?
This meta-analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney transplant recipients with data spread over different decades from all over the world.
So the level of evidence is 1
Summarize the pregnancy outcome presented by this study?
Pregnancy outcomes:
Live birth rate was 72.9% with the lowest rate is in Africa followed with Asia.
Miscarriages rate was 15.4% with the highest rate again in Africa and in South America.
Induced abortions rate was 12.4% with highest rate in South America followed by Asia, Oceania, North America, Europe and Africa.
Stillbirths’ rate was 5.1% with the highest rate present in Asia and lowest is in Africa.
Ectopic pregnancies was 2.4% with highest rate is in Asia.
Maternal outcomes:
Rates of preeclampsia was 21.5 % % with the highest rate in Oceania followed by North America and lowest in Africa.
Cesarean section rate was 62.6% which was highest in South America followed by Africa.
Gestational diabetes rate was 5.7% with the lowest rate in Oceania.
Pregnancy induced hypertension rate was 24.1 and being highest in South America and lowest in Africa.
Fetal outcomes:
Rate of preterm birth was 43.1% defined by babies born alive before 37 weeks of gestation, being highest in South America and lowest in North America.
Neonatal mortality was 3.8% with the highest rate being in Africa and lowest rate in North America.
The mean gestational age for newborns was 34.9 weeks and the mean birth weight was 2470 g.
Graft outcomes:
The overall acute rejection rate during pregnancy was 9.4% being highest in Asia followed by South America, Oceania, Europe, North America and Africa.
Graft failure showed large variability in the follow up period ranging from 1 year to 14 years. The two-year post pregnancy graft loss reported was 9.2%. The change in preconception creatinine and post-pregnancy creatinine was statistically significant (1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl).
Time of conception
Outcomes were stratified by interval between pregnancy and kidney transplant into:
Ø < 2 years
Ø 2–3 years
Ø 3 years
Adverse pregnancy outcomes of induced abortion rates and neonatal deaths were highest in the 2–3 year interval (16% and 9%), following kidney transplant as compared to < 2 year interval (11% and 3%) and > 3 year interval (10 and 4%).
Cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years (68% and 73%) than > 3 year( 75% and 65%) and < 2 year interval ( 74 and 42%).
Maternal complication of preeclampsia was higher in the 2–3 interval , and > 3 year interval than < 2 year interval (24% vs. 23% vs. 13%).
Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and<2 interval (16% vs. 14% vs. 10%).
Maternal age for conception:
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs. 76%).
Rates of spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
The level of this study is a level 1 meta-analysis review.
Summarise the pregnancy outcome presented by this study?
87 studies meta-analysis between 2000-2017 discussed the outcome of pregnancy post kidney transplant, there were 6712 pregnancies in 4174 kidney transplant recipients.
Pregnancy outcomes as compared to the general population:
Maternal outcomes:
* Preeclampsia was 21.5%
* Cesarean section was 62.6%
* Gestational diabetes was 5.7%.
* Pregnancy-induced hypertension was 24.1%
Fetal outcomes
The rate of preterm birth was 43.1% ( babies born alive before 37 weeks of gestation)
neonatal mortality was 3.8%
Graft outcomes
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%.
Time of conception:
The best time of conception after renal transplantation remains an area of controversy. According to American Society of Transplantation guidelines, the ideal time is between 1 and 2 years after transplantation .
Thank You
** What is the level of evidence of this study?
Level of Evidence 1
Meta-Analysis Systemic Reviews
** Summarise the pregnancy outcome presented by this
# This meta analysis of 87 studies from (2000 to 2017) conducted the outcomes of pregnancy in kidney transplanted women , there were 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years.
# Pregnancy outcomes as compared to the general population:
* Live birth rates were higher compared to the US general population (72.9% vs. 62%).
* Miscarriage rate was slightly lower than US general population (15.4% vs. 17.1%), but higher in Africa (21.0%) and South America (20.2%).
* Induced abortion rate was lower than the US general population (12.4% vs. 18.6%), but it was highest in South America (19.8%), Asia (13.3%), Oceania (11.5%), North America (10.9%), Europe (10.0%) and Africa (7.7%).
* Stillbirth rate was higher than the US general population (5.1% vs. 0.6%), but was highest in Asia (6.6% ), and lowest in Africa (2.6% ) .
* Ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%), with highest rate in Asia (3.3%).
# Maternal outcomes:
* Preeclampsia was 21.5% (US, 3.8%).
* Cesarean section was 62.6% (US, 31.9%).
* Gestational diabetes was 5.7% (US, 9.2%).
* Pregnancy induced hypertension was 24.1%.
* Preeclampsia rate was highest in Oceania
(27.0%), followed by North America (25.5%) and lowest in Africa (10.5%)
# Fetal outcomes:
* Preterm birth was 43.1 %( defined by babies born alive before 37 weeks of gestation) was highest in South America (55.0%) and lowest in North America (35.4%).
* Neonatal mortality was 3.8%.
*The mean gestational age for newborns was 34.9 weeks (US mean, 38.7 weeks).
* And the mean birth weight was 2470 g (US mean, 3389 g).
*Neonatal mortality was high across all geographical regions as compared to the US mean (3.8% vs. 0.4%), with highest rate in Africa (18.4%) and lowest rate in North America (1.3%)
# Graft outcomes:
* Acute rejection rate during pregnancy
among 822 kidney transplant recipients was 9.4% which was comparable to the US mean of 9.1%, were highest in Asia (11.0%), followed by South America (10.7%), Oceania (9.1%), Europe (7.3%), North America
(6.7%) and Africa (4.8%).
* With regards to graft failure, the two year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%).
* The change in pre and post pregnancy creatinine, was statistically significant
(1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007).
# Time of conception:
* Outcomes were also stratified by interval of 3 years between pregnancy and kidney Transplant.
* induced abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to 3 year interval (16% vs. 11% vs. 10, and 9% vs. 3% vs. 4% respectively).
* Cesarean section rate and live birth rate were also less favorable in this interval of 2–3 years than > 3 year, and 3 year interval than 3 year interval followed by 2–3 interval, and<2 interval (16% vs. 14% vs. 10%).
# Maternal age for conception:
*Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years (74% vs. 76%).
*Spontaneous abortion were highest in
women 35 years followed by women with maternal age 25–34 years (20% vs. 18% vs. 11%).
* Preeclampsia rates were higher in women with maternal age > 35 years (27%) and 29–34 years (26%) followed by < 25 years (17%) and 25–29 years (14%).
Thank You
Level of evidence
1
Pregnancy outcomes
Live birth rate was 72.9%
miscarriages rate was 15.4%
induced abortions rate was 12.4%
stillbirths rate was 5.1%
and rate of ectopic pregnancies was 2.4% .
Maternal outcomes
Overall, rates of preeclampsia was 21.5% cesarean section was 62.6%
gestational diabetes was 5.7%
Fetal outcomes
Overall, rate of preterm birth was 43.1%
defined by babies born alive before 37 weeks of gestation, and
neonatal mortality was 3.8%
Graft outcomes
The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% Rates of acute renal allograft rejection were highest in Asia (11.0%), followed by South America (10.7%), Oceania (9.1%), Europe (7.3%), North America (6.7%), and Africa (4.8%)
With regards to graft failure, there was large variability in the follow up period ranging from 1 year to 14 years.
The best time of conception after renal transplantation remains an area of controversy. According to American Society of Transplantation guidelines, the ideal time is between 1 and 2 years after transplantation whereas, European best practice guidelines recommend delaying pregnancy for a period of 2 years after transplantation.
Thank You
# Level 1
# Pregnancy is very rare in ESKD pts so Tx is the only hope .
#Pregnancy in Tx carries risk on Mother , fetus and the graft .
#Maternal Complications:
*pre-eclampsia: 25 % of cases most common complication
*gestational diabetes 8 % differs according to ethnicity .
*UTI
* CS Complications
#Fetal Complications:
*preterm Labour
*IUGR
*birth defects
*Still birth
#Graft Complications: depend on
Base line KFTs , proteinuria, Graft function , immunosuppression, timing of conception (at least 1 year post Tx)
This is very short Ahmed
Level I
Compared to the general population:
In general, the majority of pregnancies result in live birth but maternal and fetal adverse events are common.
Thank You
level I
women on dialysis have a very low incidence of conception ranging from 0.9 to 7% due to disruption of the hypothalamic gonadal axis. transplantation consider the best hope to women with end-stage renal disease who wish to become pregnant. Pregnancy in a kidney transplant recipient is challenging due to the risk of adverse
· maternal complications (preeclampsia, hypertension, and gestational diabetes)
· fetal outcomes (premature birth, low birth weight, small for gestational age infants, and side effects from immunosuppressive medication).
· deterioration of allograft function.
Therefore, preconception counseling, family planning, and contraception are pertinent parts of the transplant counseling process.
The primary goal of this study was to perform a meta-analysis to systematically identify all studies of pregnancy-related outcomes in kidney transplant recipients from all around the world, and estimate pooled incidence of pregnancy outcomes, maternal complications, and fetal complications. The secondary goals were to examine the impact of pregnancy on the kidney allograft loss, and allograft rejection, identify the ideal maternal age of conception and determine the ideal time of conception between kidney transplant and pregnancy
And the results showed
· live birth rates were higher as compared to the US general population (72.9% vs. 62%) .
· miscarriage rate was slightly lower than that of the US general population (15.4% vs. 17.1%)
· Induced abortion rate was also lower than the US general population (12.4% vs. 18.6%).
· stillbirth rate was higher than the US general population (5.1% vs. 0.6%).
· The rate of ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%).
· preeclampsia were 21.5% (95% CI, 18.5– 24.9; US mean, 3.8%),
· cesarean section was 62.6% (95% CI, 57.6–67.3; US mean, 31.9%).
· gestational diabetes was 5.7% (95% CI, 3.7–8.9; US mean, 9.2%),
· pregnancy-induced hypertension was 24.1% (95% CI, 18.1–31.5).
Fetal outcomes
· preterm birth was 43.1% (95% CI, 38.7– 47.6) defined by babies born alive before 37 weeks of gestation
· neonatal mortality was 3.8% (95% CI, 2.8–5.2).
· Rates of preterm birth were highest in South America (55.0%), and lowest in North America (35.4%).
· The mean gestational age for newborns was 34.9 weeks (US mean, 38.7 weeks) and the mean birth weight was 2470 g (US mean, 3389 g).
· Neonatal mortality was high across all geographical regions as compared to the US mean (3.8% vs. 0.4%).
Graft outcomes
· The overall acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4%, which was comparable to the US mean of 9.1%.
· With regards to graft failure, a two-year post-pregnancy graft function was reported, and there were 32 cases of graft loss (9.2%). The change in preconception creatinine and post-pregnancy creatinine, was statistically significant (1.23 ± 0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007).
Excellent
Level I, meta-analysis and systematic review
This meta-analysis included a total of 87 studies, spread over a long-time frame (from 2000 to 2017), involving 6712 pregnancies in 4127 kidney transplant recipients. The pregnancy outcomes of the study are as follows:
1) Higher rates of live births than the general population, with half of them having preterm delivery. Women in the age group 29-34 years showed lower live birth rates. Spontaneous abortions were least in the 25-34 years aged women.
2) Approximately 25% had serious pregnancy related complications with higher rates of stillbirths and ectopic pregnancies than the general population
3) Lower rates of miscarriages and induced abortions seen in transplant recipients.
4) Rates of preeclampsia were 6 times higher than the general population
5) Rates of Cesarean sections were 2 times the general population
6) Gestational diabetes mellitus was less common in the transplant recipients.
7) Pregnancy induced hypertension was seen in one fourth of the transplant recipients.
8) Approximately 10 times higher neonatal mortality was seen in the transplant recipients.
9) Among the transplant recipients. the mean birth weight was less than 2500 grams and mean gestational age for newborns was 34.9 weeks.
10) Acute rejection rates were comparable to the non-pregnant transplant recipients.
11) Time of conception had bearing on pregnancy outcomes with lowest live birth rates and highest neonatal deaths seen among pregnancies in 2-3 year interval post-transplant. Cesarean sections and preeclampsia were higher in pregnancies after 2 year interval.
12) Fetal outcomes were better in pregnancies within 2 years post-transplant, but could be a manifestation of reporting bias.
Overall, the rates of maternal and fetal complications were higher in the transplant recipients, but having a better outcome than general population with preservation of graft function.
Excellent, Amit, thank you
What is the level of evidence of this study?
This is a systematic review and meta-analysis with the level of evidence 1
Summary;
Kidney transplantation is believed to be the greatest option for women with end-stage renal illness who aspire to get pregnant; nonetheless, there are several hurdles that must be overcome in order to avoid problems for both the mother and the fetus.
This study uses meta-analysis to locate all studies on pregnancy-related outcomes in kidney transplant patients from all around the globe in a systematic manner.
This study aimed to determine the prevalence of adverse pregnancy outcomes as well as maternal and fetal problems. In addition, the influence of pregnancy on kidney allograft loss and allograft rejection will be investigated, as will the identification of the optimal maternal age at which to conceive and the determination of the optimal period between kidney transplant and pregnancy.
Results:
Women who had major pregnancy difficulties, which included at least one of the following: preterm delivery, first or second-trimester loss, stillbirth, or neonatal mortality, accounted for one-quarter of all women.
When compared to the most current national statistics from the United States, the rates of preterm birth, stillbirth, and infant death were all higher.
Although the live birth rates in women following kidney transplantation were higher than in the general population (73 per cent vs 62 per cent), a study of health utilization in the United States indicated a significantly lower live birth rate in kidney transplant patients (55 per cent).
Preeclampsia was diagnosed in one-quarter of the women, and the incidence of preeclampsia was almost six times greater than in the general US population (21.5 per cent vs. 3.8 per cent).
Because preexisting hypertension and proteinuria are widespread in kidney transplant patients, the diagnosis of superimposed preeclampsia might be challenging in these individuals.
Between different geographical locations, there are statistically significant variances in the incidence of gestational diabetes mellitus.
When compared to the general population, the rates of stillbirth and infant death were much higher in this cohort.
Result of the graft:
– Acute rejection, occurred at a rate equivalent to that of the general population in the United States during pregnancy among kidney transplant patients. (9.4 per cent vs. 9.1 per cent), respectively.
– Between the preconception and post-pregnancy creatinine levels, there was a statistically significant difference in creatinine levels.
Thank You
kidney transplantation restores fertility and help ESRD women wish to become pregnant
But it has alot of risks on both mother and fetus added to its risk on the graft function.
This meta-analysis systematically identify all studies of pregnancy-related outcomes in kidney transplant recipients from all around the world addressing maternal and fetal complications also the impact of pregnancy on the renal graft .
The study involved 6712 pregnancies in kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years.
Results
Maternal and fetal complications were significantly higher in transplant women than in general women population.
*Pregnancy outcomes;
The 2–3-year interval following kidney transplant had higher neonatal mortality, and lower rates of live births as compared to > 3year, and< 2-year interval.
Among the studied pregnant ladies there were;
– live-birth rate was 72.9% .
Higher incidence of the following:
-Induced abortions 12.4%
-miscarriages in first and second tirmester .
-stillbirths 5.1%.
-preterm delivery.
-ectopic pregnancies 2.4%.
-Mean gestational age was 34.9 weeks, and mean birth weight was 2470g.
*Maternal complications
-preeclampsia was six times more than general population.
-incidence if gestational diabetes (with variation in different countries),pregnancy induced hypertension ,cesarean section ,
And preterm delivery were also higher.
*Graft outcomes
-acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% which was comparable to the US mean of 9.1%.
-there were 32 cases of graft loss (9.2%).
-change in preconception creatinine and post-pregnancy creatinine, was statistically significant.
In Conclusion:
outcome of live births is favorable,despite the risks of maternal and fetal complications which must be fully discussed with the patients ,timing of pregnancy must be considered on planning for pregnancy with close monitoring of graft function, immunosuppression, blood pressure and diabetes.
Systemic review level of evidence 1
Thank You
What is the level of evidence of this study?
This is a aystemic review and meta-analysis with level of evidence 1
Summarise the pregnancy outcome presented by this study
Kidney transplantation is a successful treatment for infertility among patient with end stage renal disease. Following transplantation, there is rapid restoration of fertility. There is risk of side effects from immunosuppressive medication, and risk of deterioration of allograft function. Systematic review and meta-analyses reported incidence and outcomes of pregnancy in women with kidney transplant and evaluated incidence and outcomes of pregnancy in women with kidney transplant. 87 were included in the final study cohort. 6712 pregnancies in 4174 kidney transplant recipients. Following outcomes were demonstrated.
Pregnancy outcomes
– Live birth rate was 72.9%, live birth rates were higher as compared to the US general population (72.9% vs. 62%).
– Miscarriages rate was 15.4%, miscarriage rate was slightly lower than that of the US general population (15.4% vs. 17.1%).
– Induced abortions rate was 12.4%, induced abortion rate was also lower than the US general population (12.4% vs. 18.6%).
– Stillbirths rate was 5.1%, stillbirth rate was higher than the US general population (5.1% vs. 0.6%).
– Rate of ectopic pregnancies was 2.4%, the rate of ectopic pregnancy was slightly higher than the US general population (2.4% vs. 1.4%).
Maternal outcomes
– Rates of preeclampsia was 21.5%
– Cesarean section was 62.6%
– Gestational diabetes was 5.7%
– Pregnancy induced hypertension was 24.1%
Fetal outcomes
– preterm birth was 43.1%
– neonatal mortality was 3.8%
– mean gestational age for newborns was 34.9 weeks
Graft outcomes
Acute rejection rate during pregnancy was 9.4% comparable to the US mean of 9.1%.
In conclusion, fertility is expected to be restored shortly after kidney transplantation. Most of pregnancies successfully result in live birth, however both maternal and fetal adverse events are common. Rates of preeclampsia, still birth, and cesarean section were significantly higher than in the general population.
Thank You
What is the level of evidence of this study?
I
Summarise the pregnancy outcome presented by this study
-It is a systematic review, meta-analyses study represented 6712 pregnancies in 4174 kidney transplant recipients.
– Pregnancies in women after kidney transplant result in live birth but rates of preeclampsia was significantly higher than in the general population.
– Rates of stillbirth and neonatal mortality were significantly higher as compared to the general population.
-Gestational diabetes mellitus was high as 8.9% in Europe as compared to the general population
-The rate of cesarean section was higher than two folds as compared to the general population in the United States and varied from 60 to 77% across different geographical locations.
-There was a high rate of premature births in the transplant population and close to half of the live births were premature deliveries.
-The best time of conception in women with renal transplant is between 1 and 2 years after transplantation according to guidelines by the American Society of Transplantation, whereas European best practice guidelines recommend
delaying pregnancy for 2 years after transplantation.
– Live birth rate was lowest and neonatal deaths were highest in the 2–3 year
the interval following a kidney transplant.
-Maternal complications of cesarean section and preeclampsia were higher in the 2–3 and >3year interval post-transplant.
-Majority of patients preserve their graft function.
Thank You
What is the level of evidence of this study?
Summarise the pregnancy outcome presented by this study :
1- the overall outcome is favorable with live birth rates and the majority of patients preserve their grafts.
2- there was an increase in rates of maternal complications as pre-eclampsia,gestational DM, pregnancy induced hypertension as well as cesarean sections.
3- there was an increase in rates of fetal complications as prematurity and low birth weight.
4- finally, more larger studies are still needed for addressing the type of immunosuppression and its correlation with specific pregnancy outcome. also, the risk factors associated with specific maternal and/or fetal outcomes are still to be known.
Thank You
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review
Level 1 study
summary of the article:
the aim of the study was:
1- to determine the outcome of pregnancy
2- to determine the impact of the pregnancy on the graft
The mean maternal age was 29.6 ± 2.4 years and the mean interval between kidney transplant and pregnancy was 3.7 years.
Pregnancy outcomes:
1- Live birth rate was higher as compared to the US general population (72.9% vs 62%) and was favourable across all geographic regions. This may reflect selection bias or reporting bias in which relatively healthy women decided to pursue pregnancy and also receive better medical support by multiple specialities.
2- Miscarriage rate was slightly lower than that of the US general population (15.4% vs 17.1%), but it was higher across Africa and America.
3- Induced abortion rate was lower than US general population (12.4% vs 18.6%), which was higher than in other regions.
4- Stillbirth rate was higher than in other populations all over the world. which can be explained by prematurity, preeclampsia, and hypertension.
5- Ectopic pregnancy was high as well.
Maternal outcomes:
Pregnancy of Kidney transplant recipients was more liable to the following complications if compared to the general population
1- Preeclampsia which was of a higher rate, sixfold higher as compared to the general US population (21.5% vs 3.8%).
2- Cesarean section (62.6% vs 31.9%). This high rate can be explained by the high fetal and maternal complications among these women.
3- Gestational diabetes which increased in this type of woman as a result of immunosuppressive medication use.
4- Pregnancy-induced hypertension 24.1%
Fetal outcomes:
Pregnancy of kidney transplant recipients is associated with the following fetal outcomes:
1- Preterm birth (43.1%), the mean GA was 34.6 wks as compared to US 38.7 wks
2- Neonatal mortality (3.8%) which is high across all geographical regions
3- Low birth weight ( 2.47 g vs 3.389 g)
Graft outcomes:
1- Acute rejection, its rate during pregnancy among kidney transplant recipients was comparable to that in US general population. (9.4% vs 9.1%).
2- The change in creatinine, was statistically significant between the preconception and post-pregnancy creatinine.
Time of conception:
The best time of conception after renal transplantation remains an area of controversy. According to American Society of Transplantation guidelines, the ideal time is between 1 and 2 years after transplantation whereas, European best practice guidelines recommend delaying pregnancy for a period of 2 years after transplantation.
Thank You
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review
What is the level of evidence of this study ?
Level 1
Summary of pregnancy outcome presented by this study;
1-In women with kidney transplant ,the rates of preeclampsia, still birth, and cesarean section were significantly higher than in the general population.
2- A quarter of women were found to have serious pregnancy complications, defined as at least one of preterm delivery, first or second trimester loss, stillbirth, or neonatal death.
3- The live birth rates in women after kidney transplant were higher than in the general population and this trend was consistent throughout the globe .
4- The rates of preeclampsia were almost six fold higher as compared to the general US population .
5- The increased rate of gestational diabetes in kidney transplant patients can be well explained by the use of immunosuppressive medications like steroids and calcineurin inhibitors, the striking differences between rates of gestational diabetes accord-
ing to geographic location also highlights the importance of predisposition to diabetes due to ethnicity.
6- The rates of stillbirth and neonatal mortality were significantly higher as compared to the general population.
7- The rate of cesarean section was higher than two folds as compared to general population in United States.
8- The overall acute rejection rate during pregnancy among kidney transplant recipients was comparable to the US mean of 9.1%.
9-The change in preconception creatinine and post-pregnancy creatinine, was statistically significant.
The strength of this study ;
1-It involves a large number of pregnant renal transplant recepients from all around the globe, thus providing us with information about pregnancy outcomes for a heterogenous population.
2-It analyzed specific outcomes and identified outcomes which may require intensive management pertaining to that region.
The limitations of the study;
1- It examined pregnancy outcomes over several decades. While it is expected for the outcomes to change due to improvement in obstetric care in kidney transplant recipients over the course of time, subgroup analysis for studies from 2000 to 2017 showed consistent results.
2-There were inconsistencies in the definition of live birth rate amongst different studies that may have affected the results. Reporting bias may have affected the miscarriage rate.
3- It unable to account for differences in socioeconomics, and healthcare conditions among the different geographic regions.
Conclusion;
Although the outcome of live births is favorable, the risks of maternal and fetal complications are high in kidney transplant recipients and should be considered in patient counseling and clinical decision making.
Thank You
Systemic review- Level of Evidence -1
The fertility is significantly reduced in patients who in haemodialysis due to disruption of hypothalamic pituitary axis. Following transplantation fertility potential usually restores soon . In such situation the pregnancy is a challenge due to high risk of hypertension, pre eclempsia and fetal risks like premature births, low foetal weight and small for gestational age. There can be risks due to immunosuppression and graft dysfunction . Pre conception counselling is very important in such females. The purpose of this study was to perform meta analysis to identify all studies on pregnancy related outcomes in kidney transplant recipients and fetal complications. Also impact of pregnancy on graft loss, rejection. ideal age for conception and ideal time between transplant and pregnancy was assessed
Methodology– 4174 pregnant kidney transplant recipients out of 6712 pregnancies were enrolled.
Pregnancy Outcomes.
Still birth was higher (5%)than general population ( 0.6%)and rate of ectopic pregnancy was also high-2.4 % vs 1.4. Induced abortion and miscarriage rates were lower than US general population
Maternal outcomes.
There was twofold higher rate of C section in kidney transplant recipients as compared to general population. The rate of pre eclempsia was 6 fold higher as compared to general population likely due to factors like immunosuppressants , smoking obesity etc. Rate of of gestational diabetes was related to ethnicity.
Fetal Outcomes
Neonatal mortality was higher in African then North Americans.
Graft Outcomes
Acute rejection was noted in 9.4% while rate in general was 9.1%.
Conclusions.
It shows good outcome in term of live birth in renal transplant recipients however there are risk in terms of maternal and fetal adverse events
More studies needed in terms of type of immunosuppressive therapy in pregnancy and its specific outcomes.
Thank You
I. Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review What is the level of evidence of this study?
Level I evidence; metaanalysis & systematic review
=============================================
Summarise the pregnancy outcome presented by this study
Pregnancy outcomes after transplant:
· Higher live birth rates versus general population (73% vs.62%); universally
consistent. These higher rates may reflect that relatively healthy women
decided to conceive, & subsequently received better service by many
specialties.
· Miscarriages slightly lower than that of the US general population (15.4% vs.
17.1%);higher in Africa (21.0%), & South America (20.2%)
· Induced abortion highest in S. America (19.8), followed by Asia (13.3%),
Oceania (11.5%), N. America (10.9%), Europe (10.0%), & Africa (7.7%)
· Ectopic pregnancies 2.4%
· Stillbirths higher than the US general population (5.1% vs. 0.6%). Worldwide,
highest in Asia, & lowest in Africa.
· Ectopic pregnancy slightly higher than the US general population (2.4% vs.
1.4%); highest rate in Asia.
==============================
Maternal outcomes:
· Preeclampsia in 21.5% (US, 3.8%)
· Cesarean section was 62.6% (US, 31.9%);highest in S. America
(88.8%),followed by Africa (77.5%)
· Gestational diabetes was 5.7% (US 9.2%); lowest in Oceania (1.0%).
· PIH was 24.1%; highest in S. America (48.0%), lowest in Africa (16.1%).
· Preeclampsia rate was highest in Oceania(27%), followed by N.
America(25.5%), & lowest in Africa (10.5%)
================================
Fetal outcomes
· Preterm birth (born alive before 37 weeks of gestation)was 43.1%; highest in
S. America (55.0%), & lowest in N. America (35.4%)
· Neonatal mortality was 3.8%; high across all regions as compared to the US
mean (3.8% vs. 0.4%), with highest rate in Africa (18.4%) & lowest rate in N.
America (1.3).
· Mean gestational age for newborns was 34.9 weeks (US mean, 38.7 weeks)
· Mean birth weight was2470 g (US mean, 3389 g).
==============================
Graft outcomes
· Acute rejection rate among 822 kidney transplant recipients was 9.4% (95%)
which is comparable to the US mean of 9.1%; highest in Asia (11.0%), followed
by S. America (10.7%), Oceania (9.1%), Europe (7.3%), N. America (6.7%), &
Africa (4.8%).
· Graft loss: among 489 recipients in 12 studies where 2-year post pregnancy
graft loss was reported, there were 32 cases of graft loss (9.2%).
· Change in pre- & post-pregnancy creatinine was statistically significant (1.23 ±
0.16 mg/dl vs. 1.37 ± 0.27 mg/dl, p = 0.007).
==============================
Time of conception
· Induced abortion rates & neonatal deaths were highest in the 2–3 year interval
following transplant as compared to < 2 year interval & > 3 year interval (16%
vs. 11% vs. 10,& 9% vs. 3% vs.4% respectively).
· C/S rate & live birth rate were less favorable in this interval of 2–3 years than >
3 year, & < 2 year interval (68% vs. 75% vs. 74, & 73%vs. 65% vs. 42%
respectively).
· Preeclampsia was higher in the 2–3 interval, & > 3 year interval than < 2 year
interval (24% vs. 23% vs. 13%).
· Spontaneous abortion highest in > 3 year interval followed by 2–3 interval, &
<2 interval (16% vs. 14% vs. 10%).
===============================
Maternal age for conception
· Lower live birth rate in maternal age 29–34 years than those < 29 years (74%
vs.76%).
· Spontaneous abortion highest in women < 25 years & > 35 years followed by
women with maternal age 25–34 years (20% vs. 18% vs. 11%).
· Preeclampsia higher in maternal age > 35 years (27%) & 29–34 years (26%)
followed by < 25 years (17%) & 25–29 years (14%).
==================================
Conclusions
· This meta analysis of pregnancy outcomes in 6712 pregnancies in 4174 kidney
transplant recipients shows favorable outcomes with live birth rates
exceeding that in the recent national population.
· The graft was preserved in the majority of patients.
· Pregnancy after renal transplant poses significant risk in regards to maternal
& fetal adverse events.
· Type of immunosuppression and its correlation with pregnancy outcomes
needs to be studied.
· Standardization of definitions used in evaluating these outcomes is needed.
· Health care providers will benefit from this study in their caring for this high
risk population.
Thank You
Pregnancy outcomes in women with kidney transplant: Meta-analysis and systematic review.
Level evidence I.
Introduction:
kidney transplantation is considered the best hope to women with end-stage renal disease who wish to become pregnant but also there are many challenges meeting us related to maternal and fetal complications.
Here there is meta-analysis to systematically identify all studies of pregnancy-related outcomes in kidney transplant recipients from all around the world.
To estimate the incidences of pregnancy outcomes, maternal complications, and fetal complications. Also to examine the impact of pregnancy on the kidney allograft loss, allograft rejection, identify ideal maternal age of conception, and determine ideal time of conception between kidney transplant and pregnancy.
Results:
Overall, there were 6712 pregnancies in 4174 kidney transplant recipients. Mean maternal age was 29.6 ± 2.4 years and mean interval between kidney transplant and pregnancy was 3.7 years data collected from selected 87 studies.
Pregnancy outcomes.
Live birth rate was 72.9% which is were higher as compared to the US general population.
Miscarriages rate was 15.4% which was lower than that of the US general population , but higher across Africa , and South America.
Induced abortions rate was 12.4%.
Stillbirths rate was 5.1% which was higher than the US general population.
and rate of ectopic pregnancies was 2.4% .
Maternal outcomes.
preeclampsia was 21.5% which was highest in Oceania followed by North America and lowest in Africa.
Cesarean section was 62.6% which was highest in South America , followed by Africa.
Gestational diabetes was 5.7% , Oceania had the lowest rates.
Pregnancy induced hypertension was 24.1% with highest rate was reported in South America , while lowest rate was in Africa.
Fetal outcomes.
Preterm birth was 43.1% was highest in South America and lowest in North America.
Neonatal mortality was 3.8% was highest rate in Africa and lowest rate in North America.
The mean gestational age for newborns was 34.9 weeks and the mean birth weight was 2470 g.
Graft outcomes.
Acute rejection rate during pregnancy among 822 kidney transplant recipients was 9.4% was highest in Asia , followed by South America.
Graft failure among 489 recipients in 12 studies where two-year post pregnancy graft loss was reported, there were 32 cases of graft loss (9.2%).
Time of conception.
Abortion rates and neonatal deaths were highest in the 2–3 year interval following kidney transplant as compared to < 2 year interval and > 3 year interval .
Maternal complication of preeclampsia was higher in the 2–3 interval, and > 3 year interval than < 2 year interval.
Spontaneous abortion rates were highest in > 3 year interval followed by 2–3 interval, and < 2 interval.
Maternal age for conception.
Lower live birth rate was observed in women with maternal age 29–34 years than those < 29 years.
Spontaneous abortion were highest in women < 25 years and > 35 years followed by women with maternal age 25–34 years.
Preeclampsia rates were higher in women with maternal age > 35 years and 29–34 years followed by < 25 years and 25–29 years.
Conclusions.
Pregnancy in kidney transplant recipients showed favorable outcomes with live birth rates exceeding that in the recent national population. Majority of patients preserve their graft.
With significant risk in terms of maternal and fetal adverse events, including increased rates of preeclampsia, gestational diabetes, cesarean section rates, and pregnancy induced hypertension so should be considered in patient counseling and clinical decision making.
Differences between non-transplant/non-pregnant:
Survival with graft function was comparable to non-pregnant transplant recipient.
Acute rejection rates were similar in pregnant and non-pregnant transplant recipients.
Thank You
A) Pregnancy outcomes ;
1.Live births
2.Induced abortion
3.Ectopic pregnancy
B) Maternal outcomes ;
1.Pre-eclampsia
2.Pregnancy-induced hypertension
3.Gestational diabetes mellitus
4.Increased rates of cesarean
C) Fetal outcomes ;
1.Preterm births
2.Low birth weight
3.Neonatal deaths
D) Graft outcomes ;
1.Acute rejections
2.Grafts failure
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