Pregnancy: CKD, Dialysis, and Transplant Patients

Q) I was having a “discussion” over lunch about CKD, pregnancy, and transplant. I said that dialysis patients cannot get pregnant, but someone said I was wrong. A friend said that transplant patients should not get pregnant because of the toxicity of the immunosuppressant medications they take, but another practitioner said that was in the “olden days.” What is the current state of the CKD, dialysis, and transplant patient and pregnancy? 

The first healthy baby delivered by a pregnant kidney transplant patient was born in 1958. With the advances in treatment of kidney disease, we are now seeing more pregnancies in these patients. However, they are still considered high risk and should be monitored by a transplant nephrologist and a high-risk obstetrician.⁴

 CKD patients (not on dialysis) are at increased risk for pregnancy complications. Maternal risks include gestational hypertension, preeclampsia/eclampsia, ESRD, or death. Fetal complications include prematurity, small-for-gestational-age babies, and stillbirth. It is very important to control hypertension because it is directly linked to fetal outcome; however, not all blood pressure medications are safe in pregnancy. ACE inhibitors, for example, are teratogenic and absolutely contraindicated.⁴

Fertility is decreased in dialysis patients; however, pregnancy occurs in 0.3% to 1.5% of women of childbearing age on dialysis. Pregnancy should be confirmed with an ultrasound because serum β-human chorionic gonadotropin can be falsely elevated in ESRD.⁵

It also can be difficult to monitor pregnancy weight gain due to fluid gains between dialysis treatments. Dialysis prescriptions should be increased either in time or frequency (or both), with a goal of keeping the blood urea nitrogen concentration below 50 mg/dL to improve maternal and fetal outcomes.^6,7 Other important factors to control are metabolic acidosis, hypocalcemia, and anemia (increased erythropoietin-stimulating agents may be needed). Frequent uterine and fetal monitoring is also indicated to prevent preterm labor due to the dialysis process. Preeclampsia, prematurity, low birth weight, and hypertension are the most common risks in these pregnancies.⁸

Renal transplantation often returns fertility to normal and allows pregnancy to occur; however, it is recommended that female patients wait until one year post-transplant if the transplanted kidney is from a living related donor (two years if from a deceased donor), have a serum creatinine level less than 1.5 mg/dL, and a urinary protein level less than 500 mg/d.⁹ The immunosuppression regimen usually needs adjustment because certain immunosuppressants are contraindicated in pregnancy and have been linked to teratogenic effects; however, data is still limited in this area.^10,11 Pregnant transplant recipients are at higher risk for preeclampsia, gestational diabetes, preterm delivery, small-for-gestational-age babies, miscarriage, stillbirth, neonatal death, and congenital abnormalities.¹²

The National Transplantation Pregnancy Registry (www.ntpr.giftoflifeinstitute.org/) is an ongoing registry in the United States that reports on transplant pregnancies and their outcomes.  Data collected by the registry show that there have been many healthy pregnancies without any adverse maternal or fetal outcomes among transplant recipients.

Mandy Trolinger, MS, RD, PA-C

Denver Nephrology
Denver, CO

Personal Note: Mandy is a two-time kidney transplant recipient. She delivered a healthy baby boy in 2012.

REFERENCES

1. Wang I-K, Muo C-H, Liang C-C, et al.  Association between hypertensive disorders during pregnancy and end-stage renal disease: a population-based study. CMAJ. 2013;85: 207-213.

2. McPhee SJ, Papadakis MA, Tierney LM, et al. Current Medical Diagnosis and Treatment. 47th ed. New York, NY: McGraw-Hill/Lange; 2008.

3. Männistö T, Mendola P, Vääräsmäki M, et al. Elevated blood pressure in pregnancy and subsequent chronic disease risk. Circulation. 2013;127:681-690.

4. Nevis IF, Reitsma A, Dominic A, et al. Pregnancy outcomes in women with chronic kidney disease: a systematic review. Clin J Am Soc Nephrol. 2011;6:2587-2598.

5. Hou S. Pregnancy in chronic renal insufficiency and end-stage renal disease. Am J Kidney Dis. 1999;33:235-252.

6. Davison JM. Dialysis, transplantation, and pregnancy. Am J Kidney Dis. 1991;17:127-132.

7. Asamiya Y, Otsubo S, Matsuda Y, et al. The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int. 2009;75:1217-1222.

8. Giatras I, Levy DP, Malone FD, et al. Pregnancy during dialysis: case report and management guidelines. Nephrol Dial Transplant. 1998;13:3266-3272.

9. McKay DB, Josephson MA. Pregnancy in recipients of solid organs—effects on mother and child. N Engl J Med. 2006;354:1281-1293.

10. Sifontis NM, Coscia LA, Constantinescu S, et al. Pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolate mofetil or sirolimus. Transplantation. 2006;82:1698-1702.

11. Kainz A, Harabacz I, Cowlrick IS, et al. Review of the course and outcome of 100 pregnancies in 84 women treated with tacrolimus. Transplantation. 2000;70:1718-1721.

12. Josephson MA. Pregnancy in renal transplant recipients: more questions answered, still more asked. Clin J Am Soc Nephrol. 2013;8: 182-183.

Q) I was having a “discussion” over lunch about CKD, pregnancy, and transplant. I said that dialysis patients cannot get pregnant, but someone said I was wrong. A friend said that transplant patients should not get pregnant because of the toxicity of the immunosuppressant medications they take, but another practitioner said that was in the “olden days.” What is the current state of the CKD, dialysis, and transplant patient and pregnancy? 

The first healthy baby delivered by a pregnant kidney transplant patient was born in 1958. With the advances in treatment of kidney disease, we are now seeing more pregnancies in these patients. However, they are still considered high risk and should be monitored by a transplant nephrologist and a high-risk obstetrician.⁴

 CKD patients (not on dialysis) are at increased risk for pregnancy complications. Maternal risks include gestational hypertension, preeclampsia/eclampsia, ESRD, or death. Fetal complications include prematurity, small-for-gestational-age babies, and stillbirth. It is very important to control hypertension because it is directly linked to fetal outcome; however, not all blood pressure medications are safe in pregnancy. ACE inhibitors, for example, are teratogenic and absolutely contraindicated.⁴

Fertility is decreased in dialysis patients; however, pregnancy occurs in 0.3% to 1.5% of women of childbearing age on dialysis. Pregnancy should be confirmed with an ultrasound because serum β-human chorionic gonadotropin can be falsely elevated in ESRD.⁵

It also can be difficult to monitor pregnancy weight gain due to fluid gains between dialysis treatments. Dialysis prescriptions should be increased either in time or frequency (or both), with a goal of keeping the blood urea nitrogen concentration below 50 mg/dL to improve maternal and fetal outcomes.^6,7 Other important factors to control are metabolic acidosis, hypocalcemia, and anemia (increased erythropoietin-stimulating agents may be needed). Frequent uterine and fetal monitoring is also indicated to prevent preterm labor due to the dialysis process. Preeclampsia, prematurity, low birth weight, and hypertension are the most common risks in these pregnancies.⁸

Renal transplantation often returns fertility to normal and allows pregnancy to occur; however, it is recommended that female patients wait until one year post-transplant if the transplanted kidney is from a living related donor (two years if from a deceased donor), have a serum creatinine level less than 1.5 mg/dL, and a urinary protein level less than 500 mg/d.⁹ The immunosuppression regimen usually needs adjustment because certain immunosuppressants are contraindicated in pregnancy and have been linked to teratogenic effects; however, data is still limited in this area.^10,11 Pregnant transplant recipients are at higher risk for preeclampsia, gestational diabetes, preterm delivery, small-for-gestational-age babies, miscarriage, stillbirth, neonatal death, and congenital abnormalities.¹²

The National Transplantation Pregnancy Registry (www.ntpr.giftoflifeinstitute.org/) is an ongoing registry in the United States that reports on transplant pregnancies and their outcomes.  Data collected by the registry show that there have been many healthy pregnancies without any adverse maternal or fetal outcomes among transplant recipients.

Mandy Trolinger, MS, RD, PA-C

Denver Nephrology
Denver, CO

Personal Note: Mandy is a two-time kidney transplant recipient. She delivered a healthy baby boy in 2012.

REFERENCES

1. Wang I-K, Muo C-H, Liang C-C, et al.  Association between hypertensive disorders during pregnancy and end-stage renal disease: a population-based study. CMAJ. 2013;85: 207-213.

2. McPhee SJ, Papadakis MA, Tierney LM, et al. Current Medical Diagnosis and Treatment. 47th ed. New York, NY: McGraw-Hill/Lange; 2008.

3. Männistö T, Mendola P, Vääräsmäki M, et al. Elevated blood pressure in pregnancy and subsequent chronic disease risk. Circulation. 2013;127:681-690.

4. Nevis IF, Reitsma A, Dominic A, et al. Pregnancy outcomes in women with chronic kidney disease: a systematic review. Clin J Am Soc Nephrol. 2011;6:2587-2598.

5. Hou S. Pregnancy in chronic renal insufficiency and end-stage renal disease. Am J Kidney Dis. 1999;33:235-252.

6. Davison JM. Dialysis, transplantation, and pregnancy. Am J Kidney Dis. 1991;17:127-132.

7. Asamiya Y, Otsubo S, Matsuda Y, et al. The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int. 2009;75:1217-1222.

8. Giatras I, Levy DP, Malone FD, et al. Pregnancy during dialysis: case report and management guidelines. Nephrol Dial Transplant. 1998;13:3266-3272.

9. McKay DB, Josephson MA. Pregnancy in recipients of solid organs—effects on mother and child. N Engl J Med. 2006;354:1281-1293.

10. Sifontis NM, Coscia LA, Constantinescu S, et al. Pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolate mofetil or sirolimus. Transplantation. 2006;82:1698-1702.

11. Kainz A, Harabacz I, Cowlrick IS, et al. Review of the course and outcome of 100 pregnancies in 84 women treated with tacrolimus. Transplantation. 2000;70:1718-1721.

12. Josephson MA. Pregnancy in renal transplant recipients: more questions answered, still more asked. Clin J Am Soc Nephrol. 2013;8: 182-183.

Q) I was having a “discussion” over lunch about CKD, pregnancy, and transplant. I said that dialysis patients cannot get pregnant, but someone said I was wrong. A friend said that transplant patients should not get pregnant because of the toxicity of the immunosuppressant medications they take, but another practitioner said that was in the “olden days.” What is the current state of the CKD, dialysis, and transplant patient and pregnancy? 

The first healthy baby delivered by a pregnant kidney transplant patient was born in 1958. With the advances in treatment of kidney disease, we are now seeing more pregnancies in these patients. However, they are still considered high risk and should be monitored by a transplant nephrologist and a high-risk obstetrician.⁴

 CKD patients (not on dialysis) are at increased risk for pregnancy complications. Maternal risks include gestational hypertension, preeclampsia/eclampsia, ESRD, or death. Fetal complications include prematurity, small-for-gestational-age babies, and stillbirth. It is very important to control hypertension because it is directly linked to fetal outcome; however, not all blood pressure medications are safe in pregnancy. ACE inhibitors, for example, are teratogenic and absolutely contraindicated.⁴

Fertility is decreased in dialysis patients; however, pregnancy occurs in 0.3% to 1.5% of women of childbearing age on dialysis. Pregnancy should be confirmed with an ultrasound because serum β-human chorionic gonadotropin can be falsely elevated in ESRD.⁵

It also can be difficult to monitor pregnancy weight gain due to fluid gains between dialysis treatments. Dialysis prescriptions should be increased either in time or frequency (or both), with a goal of keeping the blood urea nitrogen concentration below 50 mg/dL to improve maternal and fetal outcomes.^6,7 Other important factors to control are metabolic acidosis, hypocalcemia, and anemia (increased erythropoietin-stimulating agents may be needed). Frequent uterine and fetal monitoring is also indicated to prevent preterm labor due to the dialysis process. Preeclampsia, prematurity, low birth weight, and hypertension are the most common risks in these pregnancies.⁸

Renal transplantation often returns fertility to normal and allows pregnancy to occur; however, it is recommended that female patients wait until one year post-transplant if the transplanted kidney is from a living related donor (two years if from a deceased donor), have a serum creatinine level less than 1.5 mg/dL, and a urinary protein level less than 500 mg/d.⁹ The immunosuppression regimen usually needs adjustment because certain immunosuppressants are contraindicated in pregnancy and have been linked to teratogenic effects; however, data is still limited in this area.^10,11 Pregnant transplant recipients are at higher risk for preeclampsia, gestational diabetes, preterm delivery, small-for-gestational-age babies, miscarriage, stillbirth, neonatal death, and congenital abnormalities.¹²

The National Transplantation Pregnancy Registry (www.ntpr.giftoflifeinstitute.org/) is an ongoing registry in the United States that reports on transplant pregnancies and their outcomes.  Data collected by the registry show that there have been many healthy pregnancies without any adverse maternal or fetal outcomes among transplant recipients.

Mandy Trolinger, MS, RD, PA-C

Denver Nephrology
Denver, CO

Personal Note: Mandy is a two-time kidney transplant recipient. She delivered a healthy baby boy in 2012.

REFERENCES

1. Wang I-K, Muo C-H, Liang C-C, et al.  Association between hypertensive disorders during pregnancy and end-stage renal disease: a population-based study. CMAJ. 2013;85: 207-213.

2. McPhee SJ, Papadakis MA, Tierney LM, et al. Current Medical Diagnosis and Treatment. 47th ed. New York, NY: McGraw-Hill/Lange; 2008.

3. Männistö T, Mendola P, Vääräsmäki M, et al. Elevated blood pressure in pregnancy and subsequent chronic disease risk. Circulation. 2013;127:681-690.

4. Nevis IF, Reitsma A, Dominic A, et al. Pregnancy outcomes in women with chronic kidney disease: a systematic review. Clin J Am Soc Nephrol. 2011;6:2587-2598.

5. Hou S. Pregnancy in chronic renal insufficiency and end-stage renal disease. Am J Kidney Dis. 1999;33:235-252.

6. Davison JM. Dialysis, transplantation, and pregnancy. Am J Kidney Dis. 1991;17:127-132.

7. Asamiya Y, Otsubo S, Matsuda Y, et al. The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age. Kidney Int. 2009;75:1217-1222.

8. Giatras I, Levy DP, Malone FD, et al. Pregnancy during dialysis: case report and management guidelines. Nephrol Dial Transplant. 1998;13:3266-3272.

9. McKay DB, Josephson MA. Pregnancy in recipients of solid organs—effects on mother and child. N Engl J Med. 2006;354:1281-1293.

10. Sifontis NM, Coscia LA, Constantinescu S, et al. Pregnancy outcomes in solid organ transplant recipients with exposure to mycophenolate mofetil or sirolimus. Transplantation. 2006;82:1698-1702.

11. Kainz A, Harabacz I, Cowlrick IS, et al. Review of the course and outcome of 100 pregnancies in 84 women treated with tacrolimus. Transplantation. 2000;70:1718-1721.

12. Josephson MA. Pregnancy in renal transplant recipients: more questions answered, still more asked. Clin J Am Soc Nephrol. 2013;8: 182-183.