Reproduction after Kidney Transplant

1. IMMUNOSUPPRESSION AND REPRODUCTIVE HEALTH
AFTER KIDNEY TRANSPLANTATION
ANUPAM CHANDRA, MD,1 KARSTEN MIDTVEDT, MD, PHD,2 ANDERS ÅSBERG, PHD,2,3 AND IVAR
EIDE, MD, PHD1
Transplantation: November 2019. Vol 103. N 11
Journal Club Presentation 11/21/19
Reggie Lafleur, MD

2. INTRODUCTION
• Does Kidney transplant reduces sexual function and fertility in
most patients with end-stage renal disease?
• Fertility . Can I expect improvement of
libido/menstruation/erection/fertility?
•
Does immunosuppressive drug therapy adversely affect sexual
function and fertility?
Transplantation: November 2019. Vol 103. N 11

3. FREQUENTLY ASKS QUESTIONS
Fatherhood.
What is the risk of fetal adverse effects/congenital malformations
from parental immunosuppressive drug exposure?
Pregnancy .
• When is it safe to become pregnant after transplantation and
what contraceptive method should be used in the meantime?
• What immunosuppressive drugs are considered safe in
pregnancy?
• Will pregnancy/adjustment of immunosuppressive regimen
affect the risk of rejection and short- and long-term graft
function?
Transplantation: November 2019. Vol 103. N 11

4. PHARMACOLOGICAL AND NON-PHARMACOLOGICAL FACTORS THAT MAY
AFFECT FERTILITY AFTER KIDNEY TRANSPLANTATION
Drugs
- CS, CNI, AZA .
- MPA, mTORi, Belatacept, Basiliximab, ATG,Rituximab
- Antiviral:
Non pharmacological.
• Renal dysfunction
• Uremic Toxins
• Dialysis
• CMV infection
AZA, azathioprine; CNI, calcineurin inhibitor; CS, corticosteroids; MPA, mycophenolic acid; mTORi, mammalian target
of rapamycin inhibitor. Transplantation: November 2019. Vol 103. N 11

5. PRE-CONCEPTION COUNSELLING IN FEMALE RECIPIENTS
FIGURE 1. Immunosuppressive drugs and reproductive health after kidney transplantation. *Low-risk patient according to the American
Society of Transplantation recommendation. **Prevalence of miscarriages is not known. AZA, azathioprine; CNI, calcineurin inhibitors;
MPA, mycophenolic acid; mTOR-i, mammalian target of rapamycin inhibitor.
Transplantation: November 2019. Vol 103. N 11

6. • A. In utero drug exposure
-CS, CNI, MPA, AZA
- mTORi, Belatacept, Basiliximab, Riluximab, ATG
B. Maternal disease and obstetric complications
C. Congenital malformations
D. Infant drug exposure via breastmilk
Adverse effects on maternal, fetal and neonatal health
from exposure to immunosuppressive drugs commonly
used in kidney transplant recipients
Transplantation: November 2019. Vol 103. N 11

7. Key points
Preconception counseling on timing of pregnancy and contraceptive use is essential to prevent
unintentional pregnancies. It should be given before transplantation and repeated post-
engraftment. The wishes, values, and acceptance of pregnancy-related risk of the recipient
should receive attention.
Assisted fertilization increases the risk of pre-eclampsia, but still result in live births.
An immunosuppressive regimen consisting of CS, CNI, and AZA is considered safe in pregnant
and lactating women. Whole blood CNI trough levels may be misleading in pregnant recipients.
High-dose methylprednisolone can be used to treat acute rejections during pregnancy.
Use of mTORi often precludes fertility in male recipients.
The prevalence of congenital malformations in children fathered by recipients on MPA therapy
at the time of concep- tion was at level with the general population.
Transplantation: November 2019. Vol 103. N 11

8. CONCLUSION
This review mainly focuses on unresolved issues
regarding immunosuppression and reproductive health in
KTRs and point out some related key points. There is a
need for more knowledge on, for example, the impact of in
utero exposure to mTORi and belatacept, CNI dosing
strategies during pregnancy and possible effects of
commonly used induction therapies like ATG or
basiliximab. Additional studies on the impact of paternal
MPA exposure on the fetus are also warranted. Pre-
conception counseling is mandatory and should
acknowledge the importance of recipient autonomy and
Transplantation: November 2019. Vol 103. N 11

9. QUESTIONS
1. Based on this article, An Immunosuppressive regimen consisting of corticosteroid , CNI, AZA is
considered safe in pregnancy and lactating women? True or False
2. On this review article, the recommended time for conception after kidney transplantation is 3-4
months? True or False
Transplantation: November 2019. Vol 103. N 11

10. THANK YOU