Pregnancy in Recipients of Solid-Organ Transplants
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《新英格兰医药杂志》
To the Editor: The review by McKay and Josephson (March 23 issue)1 covers most of the critical issues involved in pregnancy in recipients of solid-organ transplants. However, the rates of infections and their related complications are also high among these patients.2 Urinary tract infections are the most common bacterial infections and occur in up to 40 percent of pregnant transplant recipients, particularly in patients in whom end-stage renal disease develops after pyelonephritis. It is suggested that pregnant transplant recipients should have monthly screening urine cultures if asymptomatic bacteriuria is present3 and should be treated for two weeks if an infection is present, followed by suppressive doses of antibiotics for the remainder of the pregnancy. Cytomegalovirus (CMV) is the most common viral infection in the post-transplantation period; fetal CMV infection can be diagnosed by culturing amniotic fluid. Herpes simplex virus infection before 20 weeks of gestation is associated with an increased rate of abortion, and a positive cervical culture for the virus at term is an indication for cesarean section. An infant born to a woman who is positive for hepatitis B surface antigen should be given hepatitis B virus immune globulin within 12 hours after birth and receive hepatitis B virus vaccine.
Prasanta Padhan, M.D.
Jawaharlal Institute of Postgraduate Medical Education and Research
Pondicherry 605006, India
prasanta.padhan@gmail.com
References
McKay DB, Josephson MA. Pregnancy in recipients of solid organs -- effects on mother and child. N Engl J Med 2006;354:1281-1293.
Lessan-Pezeshki M. Pregnancy after renal transplantation: points to consider. Nephrol Dial Transplant 2002;17:703-707.
Davison JM. Pregnancy in renal allograft recipients: problems, prognosis and practicalities. Ballieres Clin Obstet Gynaecol 1994;8:501-25.
The authors reply: We thank Dr. Padhan for highlighting the risk of infections in pregnant recipients of solid-organ transplants. Although we recognize the importance of perinatal infections, space constraints limited what we could cover in the review. Urinary tract infections are common in renal-allograft recipients, whether or not they are pregnant.1 One reason to recommend pregnancy only after the first post-transplantation year is that the risk of acute CMV infection is decreased2 and CMV prophylaxis has been completed.
Although hepatitis B virus infection is a worrisome complication, hepatitis C virus (HCV) infection is particularly common in renal-transplant recipients. Fortunately, the incidence appears to be decreasing among patients who receive dialysis, which means that women who receive transplants after dialysis are now less likely to have HCV infection.3 Vertical transmission occurs in approximately 5 to 10 percent of cases.4 The likelihood of fetal transmission of HCV may be reduced or eliminated by having transplant recipients plan to become pregnant when their viral load is low or undetectable,4 data that again provide evidence of the benefit of a planned pregnancy in this population. Another viral infection that should be considered is human immunodeficiency virus (HIV) infection, particularly since HIV-positive patients are now undergoing transplantation more frequently.5
Dianne B. McKay, M.D.
Scripps Research Institute
La Jolla, CA 92037
dmckay@scripps.edu
Michelle A. Josephson, M.D.
University of Chicago
Chicago, IL 60637
References
Chuang P, Parikh CR, Langone A. Urinary tract infections after renal transplantation: a retrospective review at two US transplant centers. Clin Transplant 2005;19:230-235.
McKay DB, Josephson MA, Armenti VT, et al. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005;5:1592-1599.
Kotton CN, Fishman JA. Viral infection in the renal transplant recipient. J Am Soc Nephrol 2005;16:1758-1774.
Ohto H, Terazawa S, Sasaki N, et al. Transmission of hepatitis C virus from mothers to infants. N Engl J Med 1994;330:744-750.
Wyatt CM, Murphy B. Kidney transplantation in HIV-infected patients. Semin Dial 2005;18:495-498.
Prasanta Padhan, M.D.
Jawaharlal Institute of Postgraduate Medical Education and Research
Pondicherry 605006, India
prasanta.padhan@gmail.com
References
McKay DB, Josephson MA. Pregnancy in recipients of solid organs -- effects on mother and child. N Engl J Med 2006;354:1281-1293.
Lessan-Pezeshki M. Pregnancy after renal transplantation: points to consider. Nephrol Dial Transplant 2002;17:703-707.
Davison JM. Pregnancy in renal allograft recipients: problems, prognosis and practicalities. Ballieres Clin Obstet Gynaecol 1994;8:501-25.
The authors reply: We thank Dr. Padhan for highlighting the risk of infections in pregnant recipients of solid-organ transplants. Although we recognize the importance of perinatal infections, space constraints limited what we could cover in the review. Urinary tract infections are common in renal-allograft recipients, whether or not they are pregnant.1 One reason to recommend pregnancy only after the first post-transplantation year is that the risk of acute CMV infection is decreased2 and CMV prophylaxis has been completed.
Although hepatitis B virus infection is a worrisome complication, hepatitis C virus (HCV) infection is particularly common in renal-transplant recipients. Fortunately, the incidence appears to be decreasing among patients who receive dialysis, which means that women who receive transplants after dialysis are now less likely to have HCV infection.3 Vertical transmission occurs in approximately 5 to 10 percent of cases.4 The likelihood of fetal transmission of HCV may be reduced or eliminated by having transplant recipients plan to become pregnant when their viral load is low or undetectable,4 data that again provide evidence of the benefit of a planned pregnancy in this population. Another viral infection that should be considered is human immunodeficiency virus (HIV) infection, particularly since HIV-positive patients are now undergoing transplantation more frequently.5
Dianne B. McKay, M.D.
Scripps Research Institute
La Jolla, CA 92037
dmckay@scripps.edu
Michelle A. Josephson, M.D.
University of Chicago
Chicago, IL 60637
References
Chuang P, Parikh CR, Langone A. Urinary tract infections after renal transplantation: a retrospective review at two US transplant centers. Clin Transplant 2005;19:230-235.
McKay DB, Josephson MA, Armenti VT, et al. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005;5:1592-1599.
Kotton CN, Fishman JA. Viral infection in the renal transplant recipient. J Am Soc Nephrol 2005;16:1758-1774.
Ohto H, Terazawa S, Sasaki N, et al. Transmission of hepatitis C virus from mothers to infants. N Engl J Med 1994;330:744-750.
Wyatt CM, Murphy B. Kidney transplantation in HIV-infected patients. Semin Dial 2005;18:495-498.