Successful pregnancy outcomes following liver transplantation is predicted by renal function

Abstract

Liver transplantation (LT) is a successful treatment for both acute liver failure and end-stage liver disease. The number of women of reproductive age undergoing LT is increasing. Pregnancy outcomes are favorable, but there is still a lack of prognostic markers. We aimed to identify factors predictive of adverse pregnancy outcomes in LT recipients. An analysis of all pregnancies occurring in LT recipients from 1989 to 2016 at King's College Hospital was performed. Clinical data of 162 conceptions in 93 women were reviewed. Descriptive and regression analyses were done to examine associations between laboratory markers and hepatological scores with pregnancy outcomes of live birth and preterm birth. Median age at LT was 23 years (range, 1-41 years), with a median age at conception of 30 years (range, 18-47 years). The live birth rate was 75% (n = 121). Of live births, 35% (n = 39/110 available) were delivered preterm. Preconception creatinine levels were higher in patients who had a preterm birth (85 versus 74 μmol/L; P = 0.008), with a preconception estimated glomerular filtration rate (eGFR) <90 mL/minute significantly associated with preterm delivery (P = 0.04). Progressive decline in eGFR predicted outcome, with gestational length declining with increasing chronic kidney disease (CKD) stage: CKD 0-1 = 39 weeks (median), CKD 2 = 37 weeks, and CKD 3 = 35 weeks. The risk of preterm birth was greatest in women with an eGFR <60 mL/minute (P = 0.004). Moreover, hypertension-related complications during pregnancy, such as gestational hypertension, preeclampsia, or eclampsia, were also associated with prematurity (P = 0.01). Women taking steroid-based immunosuppression had an increased risk of infection during pregnancy or postpartum (15% versus 4%; P = 0.02). In conclusion, although the majority of women have a successful pregnancy outcome after LT, preconception renal function predicts pregnancy outcome and steroids increase risk of infection during pregnancy or postpartum. Liver Transplantation 24 606-615 2018 AASLD.

Pregnancy in Liver Transplantation

“…Overall, maternal deaths have not been reported to be higher in pregnant LT recipients when compared with the general population . Death rates during pregnancy and the postpartum phase vary between 0% and 1% . In the older studies quoting higher rates of maternal death (5%‐17%), most deaths occurred more than a year postpartum and were unlikely to be related to the pregnancy .…”

“…Rates of pre‐eclampsia in the general US population have previously been reported as 4% . Older studies in pregnant LT recipients have reported pre‐eclampsia rates of 21%‐26%, whereas newer studies have reported rates of 7%‐12% . Rates may have improved over time as a result of better management of immunosuppression and risk factors (Table ) associated with pre‐eclampsia.…”

“…Rates may have improved over time as a result of better management of immunosuppression and risk factors (Table ) associated with pre‐eclampsia. Pre‐eclampsia is the main contributing factor for preterm delivery in LT recipients . The pathophysiology behind this is not entirely understood, although the vasoconstrictive effects of calcineurin inhibitors, chronic corticosteroid use, and increased incidence of baseline hypertension and renal dysfunction are important factors.…”

“…The rate of ACR in the nonpregnant LT population is also unclear . Rates of postpartum graft rejection range between 3% and 12% . Rejection during pregnancy is likely secondary to a combination of factors: either voluntary discontinuation or reduction of immunosuppression or the effect of dilution caused by increased plasma volume during pregnancy.…”

“…Indications included chronic rejection, recurrent disease, and late hepatic artery thrombosis. In all cases, graft losses were not felt to be specifically related to the pregnancy …”