C
American Journal of Transplantation 2013; 13: 3173–3182 Wiley Periodicals Inc.
Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12452
Pregnancy Outcomes for Kidney Transplant Recipients M. L. Wyld1,2,*, P. A. Clayton1,2,3, S. Jesudason4,5, S. J. Chadban1,2,3 and S. I. Alexander1,6 1
Sydney Medical School, University of Sydney, Sydney, NSW, Australia 2 Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia 3 Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), Royal Adelaide Hospital, Adelaide, SA, Australia 4 Central and Northern Adelaide Renal and Transplantation Service, Adelaide, SA, Australia 5 Department of Medicine, University of Adelaide, Adelaide, SA, Australia 6 Centre for Kidney Research, Children’s Hospital at Westmead, Sydney, NSW, Australia Corresponding author: Melanie L. Wyld, [email protected] Pregnancy outcomes in a transplant population have not been well documented. Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and the National Perinatal Epidemiology and Statistics Unit (NPESU) were analyzed. We described pregnancy outcomes within the transplant population and compared these to outcomes for the general population. Six hundred ninety-two pregnancies in 447 transplant recipients were reported between 1971 and 2010 (ANZDATA); a corresponding 5 269 645 pregnancies were reported nationally in Australia between 1991 and 2010 (NPESU). At pregnancy transplant mothers had a median age of 31 years (interquartile range [IQR]: 27, 34), a median creatinine of 106 mmol/L (IQR: 88, 1103 mmol/L) and a functioning transplant for a median of 5 years (IQR: 3, 9). The mean gestational age at birth was 35 5 weeks in transplant recipients, significantly shorter than the national average of 39 weeks (p < 0.0001). Mean live birth weight for transplant recipients was 873 g lower than the national average (2485 783 g vs. 3358 2 g); a significant difference remained after controlling for gestational age. There was lower perinatal survival rate in babies born to transplant recipients, 94% compared with 99% nationally (p < 0.001). Although transplant pregnancies are generally successful, outcomes differ from the general population, indicating these remain high-risk pregnancies despite good allograft function. Keywords: ANZDATA, IVF, pregnancy, kidney, transplantation, prematurity
Abbreviations: ANZDATA, Australia and New Zealand Dialysis and Transplant Registry; eGFR, estimated GFR; ESKD, end-stage kidney disease; IVF, in vitro fertilization; MMF, mycophenolate mofetil; mTOR, mammalian target of rapamycin; NPESU, National Perinatal Epidemiology and Statistics Unit Received 07 May 2013, revised 17 July 2013 and accepted for publication 02 August 2013 Kidney transplantation greatly increases the chance of pregnancy (and live birth) for women with end-stage kidney disease (ESKD). Maternal outcomes are well documented, and evidence to date suggests that in women with a wellfunctioning graft, pregnancy does not adversely impact graft function or maternal survival (1–3). Outcomes of the babies born to transplant mothers have been less well examined. Data on outcomes of babies born to women with transplants are limited and few studies have compared these with national outcomes (4). The literature on pregnancy outcomes in women with transplants is comprised of registry data from the United States, Australia and Europe, as well as a number of small single-center studies (3–7). The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) is one of the largest registries collecting pregnancy data for transplant recipients. Recent analyses of ANZDATA data have focused on maternal outcomes, and there has been little exploration of the babies’ outcomes (1). The aim of this study was to examine outcomes for babies born to women with kidney transplants, including survival and characteristics of babies born including birth weight and gestational age. We then examined these outcomes relative to outcomes for the general Australian population.
Methods Study population and data sources This study used data from ANZDATA and the Australian Institute of Health and Welfare National Perinatal Epidemiology and Statistics Unit (NPESU) annual reports. ANZDATA collects demographic, treatment and outcome data annually for all renal replacement patients from all renal units in Australia and New Zealand. We included all female patients with a pregnancy reported between
3173
Wyld et al 1971 and 2010. The following patient parameters were recorded: age, weight, height, cause of ESKD, time since transplantation, ethnicity, source of transplanted kidney, smoking status and prepregnancy immunosuppression and creatinine. Immunosuppression details are not specifically recorded prior to, or following, pregnancy but are routinely collected at months 1, 2, 3 and 6 and at years 1, 2, 3, 5, 7, 10, 15, 20, 25, 30 and 35 after transplantation. Reporting of in vitro fertilization (IVF) is optional. Estimated date of conception and maternal complications (gestational diabetes mellitus and preeclampsia) were reported for pregnancies after 2001. Outcome data included gestational age, pregnancy outcome (live birth, stillbirth, spontaneous abortion, termination), neonatal survival (>28 days), birth weight and the presence or absence of abnormal fetal morphology. Estimated GFR (eGFR) was estimated with the Modification of Diet in Renal Disease formula (8). The NPESU provides annual reports on all births, mothers and babies in Australia where birth occurs after 20 weeks gestation or when birth weight is at least 400 g. We included all published data from 1991 to 2010. We did not have access to patient-level data. It was not possible to exclude births from transplant recipients from the Australian data. However, as transplant births comprise less than 0.0001% of Australian births their inclusion does not impact overall results. Maternal data included age, ethnicity and smoking status. Baby data included gestational age, live births, stillbirths (>20 weeks gestation), neonatal mortality (death in the first 28 days of life) and perinatal mortality (death between 20 weeks gestation and the 28th days of life).
Pregnancy outcomes Pregnancy outcomes for women with transplants were live birth, stillbirth, spontaneous abortion (
American Journal of Transplantation 2013; 13: 3173–3182 Wiley Periodicals Inc.
Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12452
Pregnancy Outcomes for Kidney Transplant Recipients M. L. Wyld1,2,*, P. A. Clayton1,2,3, S. Jesudason4,5, S. J. Chadban1,2,3 and S. I. Alexander1,6 1
Sydney Medical School, University of Sydney, Sydney, NSW, Australia 2 Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia 3 Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), Royal Adelaide Hospital, Adelaide, SA, Australia 4 Central and Northern Adelaide Renal and Transplantation Service, Adelaide, SA, Australia 5 Department of Medicine, University of Adelaide, Adelaide, SA, Australia 6 Centre for Kidney Research, Children’s Hospital at Westmead, Sydney, NSW, Australia Corresponding author: Melanie L. Wyld, [email protected] Pregnancy outcomes in a transplant population have not been well documented. Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and the National Perinatal Epidemiology and Statistics Unit (NPESU) were analyzed. We described pregnancy outcomes within the transplant population and compared these to outcomes for the general population. Six hundred ninety-two pregnancies in 447 transplant recipients were reported between 1971 and 2010 (ANZDATA); a corresponding 5 269 645 pregnancies were reported nationally in Australia between 1991 and 2010 (NPESU). At pregnancy transplant mothers had a median age of 31 years (interquartile range [IQR]: 27, 34), a median creatinine of 106 mmol/L (IQR: 88, 1103 mmol/L) and a functioning transplant for a median of 5 years (IQR: 3, 9). The mean gestational age at birth was 35 5 weeks in transplant recipients, significantly shorter than the national average of 39 weeks (p < 0.0001). Mean live birth weight for transplant recipients was 873 g lower than the national average (2485 783 g vs. 3358 2 g); a significant difference remained after controlling for gestational age. There was lower perinatal survival rate in babies born to transplant recipients, 94% compared with 99% nationally (p < 0.001). Although transplant pregnancies are generally successful, outcomes differ from the general population, indicating these remain high-risk pregnancies despite good allograft function. Keywords: ANZDATA, IVF, pregnancy, kidney, transplantation, prematurity
Abbreviations: ANZDATA, Australia and New Zealand Dialysis and Transplant Registry; eGFR, estimated GFR; ESKD, end-stage kidney disease; IVF, in vitro fertilization; MMF, mycophenolate mofetil; mTOR, mammalian target of rapamycin; NPESU, National Perinatal Epidemiology and Statistics Unit Received 07 May 2013, revised 17 July 2013 and accepted for publication 02 August 2013 Kidney transplantation greatly increases the chance of pregnancy (and live birth) for women with end-stage kidney disease (ESKD). Maternal outcomes are well documented, and evidence to date suggests that in women with a wellfunctioning graft, pregnancy does not adversely impact graft function or maternal survival (1–3). Outcomes of the babies born to transplant mothers have been less well examined. Data on outcomes of babies born to women with transplants are limited and few studies have compared these with national outcomes (4). The literature on pregnancy outcomes in women with transplants is comprised of registry data from the United States, Australia and Europe, as well as a number of small single-center studies (3–7). The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) is one of the largest registries collecting pregnancy data for transplant recipients. Recent analyses of ANZDATA data have focused on maternal outcomes, and there has been little exploration of the babies’ outcomes (1). The aim of this study was to examine outcomes for babies born to women with kidney transplants, including survival and characteristics of babies born including birth weight and gestational age. We then examined these outcomes relative to outcomes for the general Australian population.
Methods Study population and data sources This study used data from ANZDATA and the Australian Institute of Health and Welfare National Perinatal Epidemiology and Statistics Unit (NPESU) annual reports. ANZDATA collects demographic, treatment and outcome data annually for all renal replacement patients from all renal units in Australia and New Zealand. We included all female patients with a pregnancy reported between
3173
Wyld et al 1971 and 2010. The following patient parameters were recorded: age, weight, height, cause of ESKD, time since transplantation, ethnicity, source of transplanted kidney, smoking status and prepregnancy immunosuppression and creatinine. Immunosuppression details are not specifically recorded prior to, or following, pregnancy but are routinely collected at months 1, 2, 3 and 6 and at years 1, 2, 3, 5, 7, 10, 15, 20, 25, 30 and 35 after transplantation. Reporting of in vitro fertilization (IVF) is optional. Estimated date of conception and maternal complications (gestational diabetes mellitus and preeclampsia) were reported for pregnancies after 2001. Outcome data included gestational age, pregnancy outcome (live birth, stillbirth, spontaneous abortion, termination), neonatal survival (>28 days), birth weight and the presence or absence of abnormal fetal morphology. Estimated GFR (eGFR) was estimated with the Modification of Diet in Renal Disease formula (8). The NPESU provides annual reports on all births, mothers and babies in Australia where birth occurs after 20 weeks gestation or when birth weight is at least 400 g. We included all published data from 1991 to 2010. We did not have access to patient-level data. It was not possible to exclude births from transplant recipients from the Australian data. However, as transplant births comprise less than 0.0001% of Australian births their inclusion does not impact overall results. Maternal data included age, ethnicity and smoking status. Baby data included gestational age, live births, stillbirths (>20 weeks gestation), neonatal mortality (death in the first 28 days of life) and perinatal mortality (death between 20 weeks gestation and the 28th days of life).
Pregnancy outcomes Pregnancy outcomes for women with transplants were live birth, stillbirth, spontaneous abortion (
