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felt to be a useful marker of subclinical chronic rejection and that these women should undergo renal biopsy to assess graft status prior to pregnancy.18

Although not frequent, both acute and chronic rejections during pregnancy have been reported to the NTPR (4% in CsA based renal recipients) suggesting that immunosuppressive doses and levels be monitored during pregnancy.

Pregnancy potentially alters drug distribution and it has been noted that cyclosporine levels drop during pregnancy.19 Some authors have suggested adjusting CsA doses during pregnancy including dose increases.20 One group advised no dose changes despite decreases in trough levels as they observed continued stable graft function during pregnancy with this approach.21 In an analysis of registry data, we noted that recipients with graft dysfunction and/or rejection or graft loss related to pregnancy had lower mean CsA doses prepregnancy and during pregnancy.22 In this group of CsA renal recipients, 37% of recipients with peripartum graft problems either decreased or discontinued CsA during pregnancy. Of interest is a recent report of a successful pregnancy outcome in a nonimmunosuppressed renal recipient. In this case the recipient had discontinued her immunosuppression 3 years prior to pregnancy with stable graft function.23 Successful pregnancies in renal recipients have also been reported with successive pregnancies, with long transplant to conception intervals, and with multiple birth outcomes.14,24-26 With regard to multiple births, it has been suggested that fetal reduction of triplets to twins would increase the likelihood of success.27

Case reports have recently appeared in the literature of successful pregnancies in renal recipients maintained on tacrolimus.28-30 One report described a twin pregnancy, where both newborns developed respiratory and cardiopulmonary difficulties, one of whom died as a result of a thrombotic cardiomyopathy (the only such case reported to the NTPR).31

Tables 21.3-21.5 show comparisons of pregnancy outcomes for female renal recipients reported to the NTPR, including two of the newer immunosuppressive agents.32 Reports to the registry of dose management with these agents during pregnancy are summarized in Table 21.6.22,32

Liver, Liver-Kidney

Successful pregnancy outcomes have been described in female liver recipients on CsA-based and tacrolimus-based regimens.33-37 In a recent report from the Pittsburgh group (Table 21.2), one newborn had unilateral polycystic renal disease, which was the only structural anomaly.37 There were no neonatal deaths in the NTPR group of tacrolimus- treated liver recipients (Table 21.2). In a prior registry report of 58 female liver recipients (89 pregnancies, the majority CsA-based), poorer newborn outcomes were noted in 10 recipients with biopsy-proven rejection during pregnancy. Overall, there were 4 maternal deaths with recipients having recurrent hepatitis C with successive pregnancies suggesting a group at higher risk. No specific patterns of malformations were reported in the newborn.38 Case reports of successful pregnancy outcomes in female liver-kidney recipients and in female liver recipients transplanted during pregnancy have appeared in the literature and have been reported to the NTPR.37,39-44

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