While deceased donor transplant may be associated with graft loss after pregnancy, there is no data linking pregnancy itself to graft loss, according to a recent study published in the American Journal of Obstetrics & Gynecology.
Takeaways
- Pregnancy after kidney transplant poses significant risks, including preterm birth, preeclampsia, and cesarean delivery, with over 14,000 cases reported, highlighting the importance of monitoring and managing obstetrical complications in this population.
- Deceased donor graft recipients are at a higher risk of graft loss within 2 years post-pregnancy compared to living donor recipients, emphasizing the need for targeted preconception counseling and follow-up care for this subgroup.
- Acute graft rejection during pregnancy or within 3 months post-delivery is associated with a 53% rate of preterm delivery and increased short-term graft loss, underscoring the intricate relationship between maternal health and graft function.
- The study highlights the importance of considering donor type in assessing graft loss risk among pregnant kidney transplant recipients and underscores the necessity for tailored approaches to preconception counseling and post-pregnancy monitoring in this vulnerable population.
- The study's findings suggest that the timing and type of kidney transplant donor significantly impact graft survival in pregnant recipients, emphasizing the need for personalized care plans and vigilant monitoring to mitigate the risk of graft loss, particularly for those with deceased donor grafts.
Over 14,000 cases of pregnancy after kidney transplant have been reported, with high obstetrical morbidity risk reported among pregnant kidney transplant recipients. This includes preterm birth, preeclampsia, and cesarean delivery.
Acute graft rejection has been associated with a 53% rate of delivery before 32 weeks’ gestation and a high rate of short-term graft loss, indicating maternal and fetal consequences from graft dysfunction. Currently, there is little data about graft loss among kidney transplant patients accounting for all contemporary risk factors.
To evaluate the association between donor types and obstetrical and graft morbidity risks among pregnant kidney recipients, investigators conducted a retrospective cohort study. Participants included adult kidney transplant recipients with a pregnancy after transplant recorded in the Transplant Pregnancy Registry International.
Patients with transplantation before the year 2000 or lacking information about the type of organ donor were excluded from the analysis. Donor types included deceased donor graft, living related donor graft, and living unrelated donor graft.
Only pregnancies ending in live birth were included in the analysis of obstetrical outcomes. Perinatal risk factors for graft loss were also reported among these patients.
Graft loss within 2 years was reported as the primary outcome of the analysis. Investigators defined long-term graft loss as graft loss from the time of transplant. Serum creatinine levels were reported before, during, and after pregnancy as milligrams per deciliter.
A histologic rejection confirmed by biopsy during pregnancy or within 3 months of delivery was considered acute rejection. Severe maternal morbidity and neonatal composite morbidity were reported as secondary outcomes.
There were 638 participants included in the analysis, 310 of whom received living related donor grafts, 160 living unrelated donor grafts, and 168 deceased donor grafts. Deceased donor graft recipients were more often nulliparous, of a non-White race, and had unplanned pregnancy. Sirolimus was also more common in these patients.
Baseline creatinine levels before pregnancy and during pregnancy were increased in living related donor recipients. The shortest transplant-to-conception interval and highest previous rejection rate was reported in living unrelated donor recipients.
Graft loss within 2 years of delivery was reported by 6.7% of deceased donor recipients, 3.7% of living related donor recipients, and 1.3% of living unrelated donor recipients. Deceased donor recipients had the shortest duration between transplant and graft loss at 6.5 years, followed by living related donors at 8.6 years and living unrelated donors at 13.3 years.
Similar obstetrical outcomes were reported across donor types, with live birth rates of 60% to 70%, miscarriage rates of 25% to 38%, and pregnancy termination rates of 1% to 2%. A urinary tract infection was reported in 21.8% of deceased donor recipients and 20.6% of living related donor recipients, vs 10.1% of living unrelated donor recipients.
Severe maternal morbidity and overall neonatal composite morbidity rates did not significantly differ between groups. However, a significant association was reported between graft loss within 2 years and deceased donor transplant, with an adjusted odds ratio of 7.52.
The greatest hazard ratios for graft loss at transplant and at delivery were observed in deceased donor recipients, at 2.08 and 2.62, respectively. Graft loss near the time of pregnancy was independently associated with graft survival from transplant.
These results indicated increased short- and long-term graft loss risk from pregnancy after deceased donor kidney transplant vs living donor kidney transplant. Investigators concluded preconception counseling should be provided to deceased donor recipients.
Reference
Ophelia Y, Lisa C, Serban C, et al. Pregnancy after deceased donor vs living donor kidney transplant: associated obstetric and graft outcomes. Am J Obstet Gynecol. 2024;230:256.e1-12. doi:10.1016/j.ajog.2023.08.009
