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Renal Allograft Function and Cardiovascular Risk in Recipients of Kidney Transplantation After Successful Pregnancy
Renal Allograft Function and Cardiovascular Risk in Recipients of Kidney Transplantation After Successful Pregnancy M.J. Gutiérrez, P. González, I. Delgado, E. Gutiérrez, E. González, R.C. Siqueira, A. Andrés, and J.M. Morales ABSTRACT Successful pregnancy is one of the better indicators of quality of life for women who are of child-bearing age with restored fertility after kidney transplantation. Our objective was to evaluate whether pregnancy represented a risk factor for worsening of renal function or for cardiovascular disease among renal transplant recipients. From 1976 to 2007, we followed 30 successful pregnancies in 27 renal recipients in our hospital; three women had two twin gestations. We compared this population with 27 women with renal transplants who were not pregnant. They were of similar ages at transplantation (pregnant 31.1 ⫾ 5.4 years vs not pregnant 31.3 ⫾ 5.4 years, P ⫽ NS) and similar evolution time between kidney transplantation and pregnancy (51.5 ⫾ 36 months vs 47.2 ⫾ 41 months respective; P ⫽ NS). There were no acute rejection episodes or graft losses. Renal function measured by serum creatinine and MDRD4 at the end of pregnancy was lower among the pregnant compared with the control group: mainly, 1.1 ⫾ 0.2 mg/dL versus 0.9 ⫾ 0.2 mg/dL (P ⫽ .05), and 66 ⫾ 20 mL/min/1.73 m2 versus 80 ⫾ 26 mL/min/1.73 m2 (P ⫽ .03). At 1 and 10 years, renal function was similar among the groups. Ten pregnant women developed preeclampsia (37%) and three, gestational diabetes mellitus (11%). There was one major cardiovascular event (4%; acute myocardial infarction) among the pregnant group, whereas there were two in the control group (7.4%; stroke and severe hypertensive retinopathy). One death occurred in each group secondary to cardiovascular complications. Our results showed that successful pregnancy after renal transplantation did not represent a long-term risk factor to worsen renal function and or produce severe cardiovascular complications. Therefore, pregnancy should be promoted. for young women with renal transplants that show excellent function. UCCESSFUL PREGNANCY is one of the better indicators of quality of life for women who are of child-bearing age with restored fertility after kidney transplantation. Therefore, women with good renal function may be selected to become pregnant. There are several articles and registries showing excellent results. Gestational diabetes and preeclampsia are well-known complications in these pregnancies. However, there is little information concerning the long-term cardiovascular risk among this young, selected population. The aim of this study was to evaluate whether pregnancy represented a risk factor for kidney allograft deterioration or cardiovascular disease among renal transplant recipients. To conduct this study, we analyzed the long-term renal
S
allograft function, the cardiovascular risk, the presence of cardiovascular events, and the survival of renal transplant recipients after a successful pregnancy compared with a population nonpregnant renal transplant recipients of similarage. Pregnancy was advised according to the criteria of the European Best Practice Guidelines: at least 2 years after kidney transplantation, stable renal function with a serum From the Nephrology Department, Hospital 12 de Octubre, Madrid, Spain. Address reprint requests to Jose M. Morales, Nephrology Department, Hospital 12 de Octubre, Avda de Cordoba s/n, 28041 Madrid, Spain. E-mail: [email protected]
© 2009 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.042
Transplantation Proceedings, 41, 2399 –2402 (2009)
2399
2400
GUTIÉRREZ, GONZÁLEZ, DELGADO ET AL Table 1. Cardiovascular Risk by WHO and ISH 2003 Risk Stratification
obesity, smoking, and familiar history of cardiovascular disease (Table 1).
Blood Pressure (mm Hg) 140–159/90–99 160–179/100–109
Without risk factors 1–2 risk factors ⬎2 risk factors (target organ lesion, associated clinical condition)
Low risk Middle risk High risk
Middle risk Middle risk High risk
?180/110
High risk High risk Very high risk
Low risk, ⬍15%; middle risk, 15%–20%; high risk, ⬎20%; very high risk, ⬎30%. WHO, World Health Organization; ISH, .
creatinine low 2 mg/dL, absence of recent acute rejection episodes, absence of hypertension or an only mild disorder controlled with one antihypertensive drug, proteinuria ⬍0.5 g/d, and no pyelocalyceal dilatation on ultrasonography.1 PATIENTS AND METHODS From 1976 to 2007, 30 successful pregnancies were achieved in 27 renal recipients followed in our hospital; three women had two sets of twin gestations. We compared this population with a similaraged group of 27 nonpregnant renal transplant recipients of similar age and similar follow-up time after transplantation: pregnant ⫽ 31.1 ⫾ 5.4 years versus not pregnant ⫽ 31.3 ⫾ 5.4 years (P ⫽ ns) and 51.5 ⫾ 36 months versus 47.2 ⫾ 41 months respectively (P ⫽ NS). This retrospective observational study compared the two populations of renal transplant recipients. When pregnancy was diagnosed, mycophenolate mofetil and/or rapamycin as well as angiotensin-converting enzyme inhibitor and/or angiotensin receptor antagonists were stopped. Immunosuppressive therapy was based on calcineurin inhibitors, preferentially tacrolimus, with or without steroids. After delivery, steroid doses were increased. Appointments were performed monthly in the obstetrics and the renal transplant outpatient clinics during the gestation period, measuring renal allograft function, blood pressure, and fetal echography. We calculated the cardiovascular risk using the World Health Organization (WHO) and ISH 2003 Risk Stratification, for a serious cardiovascular event (stroke or acute myocardial infarction) in 10 years, considering also the presence of arterial hypertension, diabetes mellitus, kidney disease, periphercal arteriopathy, target organ injury, such as proteinuria, and hypertensive retinopathy, and a number of risk factors, such as age, gender, total cholesterol ⬎240 mg/dL or low-density lipoprotein cholesterol ⬎160 mg/dL or high-density lipoprotein cholesterol ⬍40 mg/dL,
RESULTS Kidney Allograft Function
As expected, before pregnancy, both groups displayed good renal function (MDRD4 ⫽ 70.7 ⫾ 21 mL/min/m2 vs 79 ⫾ 21 mL/min/m2, P ⫽ NS), without proteinuria (0.13 ⫾ 0.1 g/d vs 0.14 ⫾ 0.1 g/d, P ⫽ NS). There were no acute rejection episodes or graft losses during pregnancy and puerperium. Renal function as measured by serum creatinine and MDRD4 glomerulas filtration at the end of pregnancy was lower among the pregnant group: 1.1 ⫾ 0.2 mg/dL versus 0.9 ⫾ 0.2 mg/dL (P ⫽ .05), and 66 ⫾ 20 mL/min/1.73 m2 versus 80 ⫾ 26 mL/min/1.73 m2 (P ⫽ .03). However, at 1 and 10 years after delivery, renal function was similar among the groups (Table 2). Proteinuria at the end of pregnancy was greatest among the pregnant group: 0.8 ⫾ 1.4 g/d versus 0.1 ⫾ 0.1 g/d, (P ⫽ .02), a difference that persisted at 1 year postdelivery (0.4 ⫾ 0.6 g/d vs 0.1 ⫾ 0.1 g/d, P ⫽ .03), but disappeared at 10 years (0.3 ⫾ 0.2 g/d vs 0.4 ⫾ 0.6 g/d, P ⫽ NS). Four pregnant patients and one patient in the control group developed graft loss due to chronic allograft nephropathy. Cardiovascular Risk
Before pregnancy both groups showed similar cardiovascular risk factors according WHO and ISH 2003 Risk Stratification: 33.3% versus 37.03%, (P ⫽ NS; Table 3). All patients showed good control of blood pressure (BP): 123 ⫾ 10/80.6 ⫾ 9.5 mm Hg in the pregnant group versus 126 ⫾ 14/73.5 ⫾ 16.5 mm Hg in the control group (P ⫽ NS) on a similar number of antihypertensive drugs (0.68 ⫾ 0.7 vs 0.67 ⫾ 0.7 drugs/d, P ⫽ NS). Ten women developed preeclampsia (37%) during pregnancy and three, gestational diabetes mellitus (11%). At 1 month after delivery, mean BP was similar among both groups (Table 3), but the pregnant women received more antihypertensive drugs (0.9 ⫾ 0.9 vs 0.6 ⫾ 0.7 drugs/d; P ⫽ .05). At 1 and 10 years, these differences did not exist. Obesity measured by body mass index at 1 month and 1 year postdelivery was highest among pregnant women versus nonpregnant women: 25.2 ⫾ 4.2 kg/m2 versus 21.8 ⫾ 3.1 kg/m2 (P ⫽ .01) and 25.1 ⫾ 4 kg/m2 versus 22.2 ⫾ 3.2 kg/m2 (P ⫽ .03). This difference persisted at 10 years postdelivery: 25.2 ⫾ 3.7 kg/m2 versus 22.5 ⫾ 2.8 kg/m2 (P ⫽ .03).
Table 2. Renal Allograft Function 1 mo Postparturition
Serum creatinine (mg/dL) MDRD4 (mL/min/m2) Proteinuria (g/d)
Pregnant Group
Not Pregnant Group
1.1 ⫾ 0.2 66 ⫾ 20 0.8 ⫾ 1.4
0.9 ⫾ 0.2 80 ⫾ 26 0.1 ⫾ 0.1
12 mo Postparturition P
Pregnant Group
Not Pregnant Group
.05 .03 .02
1.2 ⫾ 0.7 65 ⫾ 21 0.4 ⫾ 0.6
1.0 ⫾ 0.2 72 ⫾ 19 0.1 ⫾ 0.1
10 y Postparturition P
Pregnant Group
Not Pregnant Group
P
NS NS .03
1.1 ⫾ 0.2 70 ⫾ 18 0.3 ⫾ 0.2
1.2 ⫾ 0.5 62 ⫾ 24 0.4 ⫾ 0.6
NS NS NS
2401
126 ⫾ 19/74 ⫾ 9 0.9 ⫾ 1.0 186 ⫾ 34 23 ⫾ 3 52
DISCUSSION
121 ⫾ 11/77 ⫾ 9 0.6 ⫾ 0.8 189 ⫾ 27 25 ⫾ 4 44
125 ⫾ 13/76 ⫾ 8 0.5 ⫾ 0.9 205 ⫾ 39 22 ⫾ 3 18.5
NS NS NS .03 .03
123 ⫾ 10/76 ⫾ 8 0.9 ⫾ 0.7 187 ⫾ 32 25 ⫾ 4 43
NS NS NS .03 NS
Cholesterol at 1 month postdelivery was higher among pregnant women compared with nonpregnant women: 235 ⫾ 47 mg/dL versus 201 ⫾ 40 mg/dL (P ⫽ .01). At 1 and 10 years postdelivery, these differences disappeared (Table 2). There was one main cardiovascular event (4%) among pregnant women, an acute myocardial infarction, while two occurred among the control group (7.4%)— one stroke and one severe hypertensive retinopathy. There was one death in each group secondary to cardiovascular complications.
Abbreviations: BP, blood pressure; CMI, .
NS .05 .01 .01 .02 126 ⫾ 16/78 ⫾ 8 0.6 ⫾ 0.7 201 ⫾ 40 22 ⫾ 3 18.5 121 ⫾ 11/75 ⫾ 9 0.9 ⫾ 0.9 235 ⫾ 47 25 ⫾ 4 48 BP (mm Hg) No. antihypertensives Cholesterol (mg/dL) CMI (kg/m2) High cardiovascular risk (%)
10 y Postparturition
Not Pregnant Group Not Pregnant Group
12 mo Postparturition
Pregnant Group P Not Pregnant Group
1 mo Postparturition
Pregnant Group
Table 3. Cardiovascular Risk Evaluation
P
Pregnant Group
P
RENAL FUNCTION AFTER PREGNANCY
These results emphasized that, in selected renal transplant recipients, pregnancy is good option with excellent results. Therefore, we should encourage young women with excellent renal function to get pregnant. Our experience is similar to data from single centers or registries but until now there has been little information concerning the longterm cardiovascular risks in women with successful pregnancies. Before pregnancy, both populations were similar. After a successful pregnancy, despite an initial decline in renal function after delivery (possibly secondary to preeclampsia), the MDRD improved, becoming similar to the control group even 10 years there after. Therefore, our results strongly suggested that pregnancy did not have a deleterious effect upon renal allograft function as other authors have reported.2 In fact, the prevalence of chronic allograft nephropathy was also similar between groups and not different from the general transplant population. Concerning cardiovascular risk, pregnancy only promotes an increased vascular score at the puerperium, fortunately without clinical expression.3– 6 However, after the puerperium and in the long-term at 10 years, the risk became similar in both populations. In fact, cardiovascular events and cardiovascular mortality were similar. Therefore, our results suggested that pregnancy did not represent a new cardiovascular risk factor for young renal transplant recipients. This study had several limitations, mainly being retrospective with a small number of patients. Neverthless, we think that this information has important clinical value. In summary, our results showed that a successful pregnancy after renal transplantation did not represent a risk factor for worsening of renal function or severe long-term cardiovascular complications. Therefore, pregnancy should be promoted for young transplant recipients with excellent renal function. REFERENCES 1. EBPG Expert Group on Renal Transplantation: European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.10. Pregnancy in renal transplant recipients. Nephrol Dial Transplant 17:50, 2002 2. Armenti VT, Radomski JS, Moritz MJ, et al: Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transplant 103, 2004
2402 3. Sturgiss SN, Davison JM: Effect of pregnancy on the longterm function of renal allografts: an update. Am J Kidney Dis 26:54, 1995 4. Kashanizadeh N, Nemati E, Sharifi-Bonab M, et al: Impact of pregnancy on the outcome of kidney transplantation. Transplant Proc 39:1136, 2007
GUTIÉRREZ, GONZÁLEZ, DELGADO ET AL 5. Fischer T, Neumayer HH, Fischer R, et al: Effect of pregnancy on long-term kidney function in renal transplant recipients treated with cyclosporine and with azathioprine. Am J transp 5:2732, 2005 6. Gutierrez MJ, Acebedo-Ribó M, Garcia-Donaire JA, et al: Pregnancy in renal transplant recipients. Transplant Proc 37:3721, 2005
S
allograft function, the cardiovascular risk, the presence of cardiovascular events, and the survival of renal transplant recipients after a successful pregnancy compared with a population nonpregnant renal transplant recipients of similarage. Pregnancy was advised according to the criteria of the European Best Practice Guidelines: at least 2 years after kidney transplantation, stable renal function with a serum From the Nephrology Department, Hospital 12 de Octubre, Madrid, Spain. Address reprint requests to Jose M. Morales, Nephrology Department, Hospital 12 de Octubre, Avda de Cordoba s/n, 28041 Madrid, Spain. E-mail: [email protected]
© 2009 Published by Elsevier Inc. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/09/$–see front matter doi:10.1016/j.transproceed.2009.06.042
Transplantation Proceedings, 41, 2399 –2402 (2009)
2399
2400
GUTIÉRREZ, GONZÁLEZ, DELGADO ET AL Table 1. Cardiovascular Risk by WHO and ISH 2003 Risk Stratification
obesity, smoking, and familiar history of cardiovascular disease (Table 1).
Blood Pressure (mm Hg) 140–159/90–99 160–179/100–109
Without risk factors 1–2 risk factors ⬎2 risk factors (target organ lesion, associated clinical condition)
Low risk Middle risk High risk
Middle risk Middle risk High risk
?180/110
High risk High risk Very high risk
Low risk, ⬍15%; middle risk, 15%–20%; high risk, ⬎20%; very high risk, ⬎30%. WHO, World Health Organization; ISH, .
creatinine low 2 mg/dL, absence of recent acute rejection episodes, absence of hypertension or an only mild disorder controlled with one antihypertensive drug, proteinuria ⬍0.5 g/d, and no pyelocalyceal dilatation on ultrasonography.1 PATIENTS AND METHODS From 1976 to 2007, 30 successful pregnancies were achieved in 27 renal recipients followed in our hospital; three women had two sets of twin gestations. We compared this population with a similaraged group of 27 nonpregnant renal transplant recipients of similar age and similar follow-up time after transplantation: pregnant ⫽ 31.1 ⫾ 5.4 years versus not pregnant ⫽ 31.3 ⫾ 5.4 years (P ⫽ ns) and 51.5 ⫾ 36 months versus 47.2 ⫾ 41 months respectively (P ⫽ NS). This retrospective observational study compared the two populations of renal transplant recipients. When pregnancy was diagnosed, mycophenolate mofetil and/or rapamycin as well as angiotensin-converting enzyme inhibitor and/or angiotensin receptor antagonists were stopped. Immunosuppressive therapy was based on calcineurin inhibitors, preferentially tacrolimus, with or without steroids. After delivery, steroid doses were increased. Appointments were performed monthly in the obstetrics and the renal transplant outpatient clinics during the gestation period, measuring renal allograft function, blood pressure, and fetal echography. We calculated the cardiovascular risk using the World Health Organization (WHO) and ISH 2003 Risk Stratification, for a serious cardiovascular event (stroke or acute myocardial infarction) in 10 years, considering also the presence of arterial hypertension, diabetes mellitus, kidney disease, periphercal arteriopathy, target organ injury, such as proteinuria, and hypertensive retinopathy, and a number of risk factors, such as age, gender, total cholesterol ⬎240 mg/dL or low-density lipoprotein cholesterol ⬎160 mg/dL or high-density lipoprotein cholesterol ⬍40 mg/dL,
RESULTS Kidney Allograft Function
As expected, before pregnancy, both groups displayed good renal function (MDRD4 ⫽ 70.7 ⫾ 21 mL/min/m2 vs 79 ⫾ 21 mL/min/m2, P ⫽ NS), without proteinuria (0.13 ⫾ 0.1 g/d vs 0.14 ⫾ 0.1 g/d, P ⫽ NS). There were no acute rejection episodes or graft losses during pregnancy and puerperium. Renal function as measured by serum creatinine and MDRD4 glomerulas filtration at the end of pregnancy was lower among the pregnant group: 1.1 ⫾ 0.2 mg/dL versus 0.9 ⫾ 0.2 mg/dL (P ⫽ .05), and 66 ⫾ 20 mL/min/1.73 m2 versus 80 ⫾ 26 mL/min/1.73 m2 (P ⫽ .03). However, at 1 and 10 years after delivery, renal function was similar among the groups (Table 2). Proteinuria at the end of pregnancy was greatest among the pregnant group: 0.8 ⫾ 1.4 g/d versus 0.1 ⫾ 0.1 g/d, (P ⫽ .02), a difference that persisted at 1 year postdelivery (0.4 ⫾ 0.6 g/d vs 0.1 ⫾ 0.1 g/d, P ⫽ .03), but disappeared at 10 years (0.3 ⫾ 0.2 g/d vs 0.4 ⫾ 0.6 g/d, P ⫽ NS). Four pregnant patients and one patient in the control group developed graft loss due to chronic allograft nephropathy. Cardiovascular Risk
Before pregnancy both groups showed similar cardiovascular risk factors according WHO and ISH 2003 Risk Stratification: 33.3% versus 37.03%, (P ⫽ NS; Table 3). All patients showed good control of blood pressure (BP): 123 ⫾ 10/80.6 ⫾ 9.5 mm Hg in the pregnant group versus 126 ⫾ 14/73.5 ⫾ 16.5 mm Hg in the control group (P ⫽ NS) on a similar number of antihypertensive drugs (0.68 ⫾ 0.7 vs 0.67 ⫾ 0.7 drugs/d, P ⫽ NS). Ten women developed preeclampsia (37%) during pregnancy and three, gestational diabetes mellitus (11%). At 1 month after delivery, mean BP was similar among both groups (Table 3), but the pregnant women received more antihypertensive drugs (0.9 ⫾ 0.9 vs 0.6 ⫾ 0.7 drugs/d; P ⫽ .05). At 1 and 10 years, these differences did not exist. Obesity measured by body mass index at 1 month and 1 year postdelivery was highest among pregnant women versus nonpregnant women: 25.2 ⫾ 4.2 kg/m2 versus 21.8 ⫾ 3.1 kg/m2 (P ⫽ .01) and 25.1 ⫾ 4 kg/m2 versus 22.2 ⫾ 3.2 kg/m2 (P ⫽ .03). This difference persisted at 10 years postdelivery: 25.2 ⫾ 3.7 kg/m2 versus 22.5 ⫾ 2.8 kg/m2 (P ⫽ .03).
Table 2. Renal Allograft Function 1 mo Postparturition
Serum creatinine (mg/dL) MDRD4 (mL/min/m2) Proteinuria (g/d)
Pregnant Group
Not Pregnant Group
1.1 ⫾ 0.2 66 ⫾ 20 0.8 ⫾ 1.4
0.9 ⫾ 0.2 80 ⫾ 26 0.1 ⫾ 0.1
12 mo Postparturition P
Pregnant Group
Not Pregnant Group
.05 .03 .02
1.2 ⫾ 0.7 65 ⫾ 21 0.4 ⫾ 0.6
1.0 ⫾ 0.2 72 ⫾ 19 0.1 ⫾ 0.1
10 y Postparturition P
Pregnant Group
Not Pregnant Group
P
NS NS .03
1.1 ⫾ 0.2 70 ⫾ 18 0.3 ⫾ 0.2
1.2 ⫾ 0.5 62 ⫾ 24 0.4 ⫾ 0.6
NS NS NS
2401
126 ⫾ 19/74 ⫾ 9 0.9 ⫾ 1.0 186 ⫾ 34 23 ⫾ 3 52
DISCUSSION
121 ⫾ 11/77 ⫾ 9 0.6 ⫾ 0.8 189 ⫾ 27 25 ⫾ 4 44
125 ⫾ 13/76 ⫾ 8 0.5 ⫾ 0.9 205 ⫾ 39 22 ⫾ 3 18.5
NS NS NS .03 .03
123 ⫾ 10/76 ⫾ 8 0.9 ⫾ 0.7 187 ⫾ 32 25 ⫾ 4 43
NS NS NS .03 NS
Cholesterol at 1 month postdelivery was higher among pregnant women compared with nonpregnant women: 235 ⫾ 47 mg/dL versus 201 ⫾ 40 mg/dL (P ⫽ .01). At 1 and 10 years postdelivery, these differences disappeared (Table 2). There was one main cardiovascular event (4%) among pregnant women, an acute myocardial infarction, while two occurred among the control group (7.4%)— one stroke and one severe hypertensive retinopathy. There was one death in each group secondary to cardiovascular complications.
Abbreviations: BP, blood pressure; CMI, .
NS .05 .01 .01 .02 126 ⫾ 16/78 ⫾ 8 0.6 ⫾ 0.7 201 ⫾ 40 22 ⫾ 3 18.5 121 ⫾ 11/75 ⫾ 9 0.9 ⫾ 0.9 235 ⫾ 47 25 ⫾ 4 48 BP (mm Hg) No. antihypertensives Cholesterol (mg/dL) CMI (kg/m2) High cardiovascular risk (%)
10 y Postparturition
Not Pregnant Group Not Pregnant Group
12 mo Postparturition
Pregnant Group P Not Pregnant Group
1 mo Postparturition
Pregnant Group
Table 3. Cardiovascular Risk Evaluation
P
Pregnant Group
P
RENAL FUNCTION AFTER PREGNANCY
These results emphasized that, in selected renal transplant recipients, pregnancy is good option with excellent results. Therefore, we should encourage young women with excellent renal function to get pregnant. Our experience is similar to data from single centers or registries but until now there has been little information concerning the longterm cardiovascular risks in women with successful pregnancies. Before pregnancy, both populations were similar. After a successful pregnancy, despite an initial decline in renal function after delivery (possibly secondary to preeclampsia), the MDRD improved, becoming similar to the control group even 10 years there after. Therefore, our results strongly suggested that pregnancy did not have a deleterious effect upon renal allograft function as other authors have reported.2 In fact, the prevalence of chronic allograft nephropathy was also similar between groups and not different from the general transplant population. Concerning cardiovascular risk, pregnancy only promotes an increased vascular score at the puerperium, fortunately without clinical expression.3– 6 However, after the puerperium and in the long-term at 10 years, the risk became similar in both populations. In fact, cardiovascular events and cardiovascular mortality were similar. Therefore, our results suggested that pregnancy did not represent a new cardiovascular risk factor for young renal transplant recipients. This study had several limitations, mainly being retrospective with a small number of patients. Neverthless, we think that this information has important clinical value. In summary, our results showed that a successful pregnancy after renal transplantation did not represent a risk factor for worsening of renal function or severe long-term cardiovascular complications. Therefore, pregnancy should be promoted for young transplant recipients with excellent renal function. REFERENCES 1. EBPG Expert Group on Renal Transplantation: European best practice guidelines for renal transplantation. Section IV: Long-term management of the transplant recipient. IV.10. Pregnancy in renal transplant recipients. Nephrol Dial Transplant 17:50, 2002 2. Armenti VT, Radomski JS, Moritz MJ, et al: Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. Clin Transplant 103, 2004
2402 3. Sturgiss SN, Davison JM: Effect of pregnancy on the longterm function of renal allografts: an update. Am J Kidney Dis 26:54, 1995 4. Kashanizadeh N, Nemati E, Sharifi-Bonab M, et al: Impact of pregnancy on the outcome of kidney transplantation. Transplant Proc 39:1136, 2007
GUTIÉRREZ, GONZÁLEZ, DELGADO ET AL 5. Fischer T, Neumayer HH, Fischer R, et al: Effect of pregnancy on long-term kidney function in renal transplant recipients treated with cyclosporine and with azathioprine. Am J transp 5:2732, 2005 6. Gutierrez MJ, Acebedo-Ribó M, Garcia-Donaire JA, et al: Pregnancy in renal transplant recipients. Transplant Proc 37:3721, 2005