Although chronic kidney disease decreases fertility, kidney transplantation provides restoration of fertility in women, enabling them to get pregnant. Data available from registries have shown that pregnancy is feasible in solid-organ transplant recipients without significant impact on long-term graft function. Despite these reassuring data, some studies have reported that one-third of female transplant recipients are still actively being counseled against pregnancy. Here, we present a patient who received a simultaneous deceased-donor kidney and pancreas transplant and who had a favorably evolved pregnancy. The 36-year-old kidney-pancreas transplant recipient conceived 5 months after her marriage. The patient was closely followed during pregnancy by a multidisciplinary team that included a nephrologist, gynecologist, and endocrinologist. Renal function and blood glucose levels remained within normal limits. She delivered her baby normally at 31 weeks of pregnancy (1.3-kg male baby). Currently, both mother and baby are doing well. Pregnancy in combined kidney and pancreas trans-plant recipients with stable graft functions is feasible but remains risky. Proper planning, modification of immunosuppressive drugs, and close monitoring are the keys to optimized maternal, fetal, and graft outcomes.
Key words : Bariatric surgery, Fertility, Kidney-pancreas transplant, Renal function
Simultaneous kidney and pancreas transplantation is the ideal treatment for patients with end-stage kidney disease secondary to type 1 diabetes mellitus. Simultaneous pancreas-kidney transplantation is a revolutionary medical way to cure diabetes mellitus and its complications in one major step. For women with type 1 diabetes mellitus and end-stage kidney disease, this procedure not only treats their disease but may also permits them to have children.1 Pregnancy is a major issue in any female transplant recipient and is not an easy decision to be accepted and approved by nephrologists. The social cir-cumstances of the patient, her husband, and their families must be considered before a decision to proceed with pregnancy.
The effects of pregnancy on organ transplant recipients have been widely described, although its impact on the mother, the fetus, and the graft is still debated. Experience in simultaneous kidney-pancreas transplantation is limited, with few repor-ted cases, which increases the uncertainty about guidelines to follow in this situation.2 Bariatric surgeries are feasible and safe procedures for selected obese renal transplant recipients.3
Here, we present a patient who received a simultaneous deceased-donor kidney and pancreas transplant and who had a favorably evolved pregnancy.
A 36-year-old female patient with type 1 diabetes mellitus that was complicated with diabetic microangiopathy (as represented by diabetic nep-hropathy, neuropathy, and retinopathy) had been maintained on hemodialysis for 2 years. Four years ago, she had received a simultaneous deceased-donor kidney and pancreas transplant at Hamed Al-Essa Organ Transplant Center of Kuwait. She had received thymoglobulin as induction and was maintained on steroids, tacrolimus, and mycophenolate mofetil. Because of her moderate obesity, she underwent bariatric surgery 1 year posttransplant. She had stable renal graft function (with serum creatinine level of around 85 μmol/L) and stable pancreatic graft function (with blood sugar and hemoglobin A1C levels maintained within normal values without any antidiabetic agents). According to the posttransplant counseling education sessions performed in our center, she was planning to marry and was keen to receive permission from her nephrologist in our center to allow her the chance for pregnancy.
After discussion with the patient and detailed explanation of the risks for both grafts and for pregnancy outcome, we agreed to permit her the chance to become pregnant. She was switched from mycophenolate mofetil to azathioprine before marriage and from amlodipine to alpha-methyldopa to control her blood pressure. She conceived spontaneously 5 months after marriage, as shown by positive β-human chorionic gonadotropin test and confirmed by ultrasonography. She was followed closely in our center and in the maternity hospital monthly until month 7 and then weekly until delivery.
The patient showed stable renal and pancreatic graft functions without any major adverse events (acute rejection, infection, or gynecologic events) during the entire course of her pregnancy. At 31 weeks, she developed vaginal bleeding and underwent assisted breech delivery under spinal anesthesia and gave birth to a male baby (1.360 kg). Both the mother and baby were doing well at follow-up. Patient graft functions were stable, and she was shifted back to mycophenolate mofetil.
Combined pancreas and kidney transplant rep-resents the best therapeutic option for patients with end-stage renal disease due to type 1 diabetes mellitus. Female recipients of pancreas-kidney transplants may have an increased chance for pregnancy because the procedure often restores fertility. Successful pregnancy is possible for female pancreas-kidney recipients.4 However, lack of information on pregnancy outcomes after combined pancreas and kidney transplant have hampered balanced medical counseling.
Experience in simultaneous kidney-pancreas transplant and pregnancy is limited, with few repor-ted cases, which have increased the uncertainty about guidelines to follow in this situation. In one study, the patient delivered by caesarean section due to fetal distress at 38 weeks of gestational age. Five months after delivery, the child showed normal development and both the pancreas and kidney grafts in the mother showed normal function.2
In this case report, we highlight a successful planned pregnancy in a woman who received a com-bined kidney-pancreas transplant. No major dele-terious effects of pregnancy were shown in both the mother and baby, except for preterm birth and low birth weight. Normand and associates5 reported that preterm delivery rates in patients were 80%, with National Transplantation Pregnancy Registry data reporting similar findings.6 Jain and associates added that 41% of babies were either preterm or premature.7
Premature birth is a common complication among pregnant solid-organ transplant recipients.6 Bösmüller and colleagues reported that prematurity is more frequent among combined kidney-pancreas trans-plant recipients than other solid-organ transplant recipients.8 Infants who are born preterm are exposed to several complications, including respiratory, bowel, immunity, cardiovascular, and neurologic disorders.9 Fortunately, there were no fetal malfor-mations in our case. This could be explained by the education sessions posttransplant about planned pregnancy and adequate timing of immunosup-pression optimization. The reported incidence of fetal malformations among kidney-pancreas transplant patient is 7.7%5, which is similar to that shown in kidney transplant recipients.10 Mycophenolate mofetil and mammalian target of rapamycin inhibitors are teratogenic immunosuppressive drugs; therefore, they require replacement as a crucial part of the plan for conception.11
Regarding maternal complications, the most challenging complication among organ transplant recipients is rejection episodes. These rejection episodes are described in the literature as being the consequence of decreased immunosuppressive drug trough levels resulting from increased maternal blood volume.12 The low incidence of rejection in the series reported by Jain and associates may have been due to differences in the risk factors in different series.7
After prenatal counseling was conducted, a decision was made to allow our patient to conceive. In vitro fertilization pregnancy is also feasible in pancreas-kidney recipients. Of course, there is a risk with pregnancy in pancreas-kidney recipients, requiring close monitoring.13 In our patient, we did not observe any abnormalities in her blood sugar levels during pregnancy. This finding was not matched with that reported by Tyden and associates who showed reduced islet mass with normal metabolic control in their report.14 This could be explained by the metabolic surgery conducted in our patient after transplant, which helped to avoid an excess load on her pancreatic graft.
Pregnancy in recipients of combined kidney and pancreas transplant with stable graft function is feasible but remains risky. Proper planning, modi-fication of immunosuppressive drugs, and close monitoring are the keys to optimized maternal, fetal, and graft outcomes.
Volume : 17
Issue : 1
Pages : 220 - 222
DOI : 10.6002/ect.MESOT2018.P75
From the 1Nephrology Department, Hamed Al-Essa Organ Transplant
Center, Ibn Sina Hospital, Sabah Area, Kuwait; and the 2Department of
Dialysis and Transplantation, Urology and Nephrology Center, Mansoura
Acknowledgements: The authors have no sources of funding for this study and have no conflicts of interest to declare.
Corresponding author: Osama Ashry Ahmed Gheith, Hamed Al-Essa Organ Transplant Center, Ministry of Health – Ibn Sina Hospital, Kuwait
Phone: +96 566641967