Young people (and even children) may also need a kidney transplant. Of course, there aren't as many on the transplant list compared to those over 50. Furthermore, young people are forced to wait on a longer list because there are few organs available for this age group. “But transplants in young people generally go very well – explains Professor Jacopo Romagnoli, head of the Kidney Transplant Unit of Fondazione Policlinico Gemelli Irccs and professor of General Surgery at the Catholic University of the Sacred Heart, Rome campus – also because they have fewer risk factors. And when we say that a kidney transplant restores a normal life, this also applies to the desire for parenthood.” In short, a woman of childbearing age who has received a kidney transplant can aspire to become pregnant. And the international conference 'Pregnancy & renal transplantation' is dedicated to this topic, a two-day debate that ends today at the Fondazione Policlinico Gemelli.
“We have known that pregnancy is possible in kidney transplanted women for at least 30 years – recalls Romagnoli, one of the organizers of the conference together with Giuseppe Grandaliano, Uoc director of Nephrology at Gemelli and full professor of Nephrology at the Catholic University, and to Antonio Lanzone, director of the Uoc of Obstetrics and obstetric pathology at the Gemelli and full professor of Gynecology and obstetrics at the Cattolica – But of course, over time the results of the transplant have improved a lot, so today women of childbearing age who have received a kidney transplant can face a pregnancy with greater serenity. Another myth to dispel is that the transplanted woman cannot breastfeed. Recent studies show that it is possible.”
During the conference, the results of a national survey organized by Gemelli on the trend of pregnancies in women with renal transplants in the last 15 years were presented. “Out of approximately 30,000 kidney transplants carried out in this period of time – recalls Romagnoli – just over 3,000 recipients were women of childbearing age, therefore possible candidates for pregnancy. However, among these, just 228 pregnancies were registered, a very low percentage, not so much due to medical contraindications, but due to a lack of knowledge of the topic. This is why it is necessary to create culture and training and this is one of the reasons that led us to organize this congress”.
“A series of pathologies, partly congenital (for example major malformations of the urinary tract) or genetically determined or immune-mediated (such as vasculitis and lupus nephritis) – explains Grandaliano – can lead to terminal renal disease, which requires dialysis therapy or renal transplant. These women are not fertile as long as they remain on dialysis; a pregnancy in these conditions is impossible and the transplant is therefore even more important because it allows these young women to face a pregnancy”.
Anti-rejection therapy during pregnancy is another of the 'hot topics' of the congress. “One of the most widespread fears of transplant recipients – highlights Romagnoli – is having a deterioration in renal function or even rejection, resulting in immunosuppressive therapy. However, these are unfounded fears.” “Pregnancy must naturally be planned – continues Grandaliano – because it is necessary to adapt immunosuppressive and antihypertensive therapy. Regarding immunosuppressive therapy, calcineurin inhibitors (cyclosporine and tacrolimus) do not cause problems; anti-proliferative drugs such as mycophenolate and m-Tor inhibitors are more at risk, as they can create problems with fetal development and must therefore be suspended when conception is planned (this applies not only to women, but also for transplanted men); these drugs must be suspended starting one month before conception and must be kept suspended throughout pregnancy and possibly breastfeeding.
During pregnancy, nephrological checks must be more stringent, with monthly monitoring of renal function and proteinuria and close control of blood pressure. In fact, even some antihypertensive drugs must be suspended during pregnancy: Ace-inhibitors, which are the gold standard of nephrological therapy, can have teratogenic effects and must therefore be suspended when planning a pregnancy. Green light instead for calcium channel blockers, alpha-methyl dopa, clonidine and some beta-blockers such as labetalol”.
Pregnancy in kidney transplant recipients presents some additional risks, which are generally well controllable if followed in specialized centres. “The greatest risks for the mother – recalls Angela Botta, of the Gemelli Obstetric Pathology Unit – are those linked to an increase in blood pressure, therefore gestational hypertension (which concerns 24% of transplanted women, compared to 3-5% of pregnancies in the general population) and pre-eclampsia (15% versus 1-2% of all pregnancies); the risk of gestational diabetes was also slightly increased (11% compared to 6-7% of other pregnancies). The risks for the fetus are above all prematurity (the average gestational age of birth in transplant recipients' pregnancies is 35 weeks, compared to 39 in the general population) and low birth weight (newborns born to transplanted mothers have an average weight of 2.5 kg compared to 3.3 kg in the general population). The risk of miscarriage, however, is only slightly increased (19% compared to 15% of the general population)”.
To minimize these risks – continues Botta – it is best to plan the pregnancy 1-2 years after the transplant, at a time when the transplanted kidney shows good functionality and eliminating all other possible risk factors (such as smoking , obesity, alcohol, sedentary lifestyle). The multidisciplinary management of these patients is fundamental and must be followed in a serious manner by a team made up of nephrologists, transplantologists and experts in maternal-fetal medicine. These skills, coordinating with each other and evaluating their respective fields, contribute to a favorable outcome of the pregnancy, both for the mother and the fetus. There is still little awareness and clarity on the breastfeeding front, so much so that many women abandon the idea of breastfeeding for fear that immunosuppressive drugs could pass into the breast milk and cause harm to the newborn. In reality, the literature shows that, using an adequate profile of immunosuppressive therapy (the same one we use during pregnancy) based on corticosteroids, calcineurin inhibitors and azathioprine, breastfeeding is possible and safe for the newborn.”
The reference centers for transplant recipients who wish to become pregnant are high-volume ones, such as that of Gemelli – a note reports – which, for living kidney transplants, is among the very first in Italy. “In the last 15 years – concludes Romagnoli – we have followed 15 transplanted women at Gemelli who have had a pregnancy (some even more than one pregnancy) and they have all gone well”.
#mother #kidney #conference #Gemelli
