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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2016  |  Volume : 27  |  Issue : 6  |  Page : 1290-1292
Obstructive nephropathy in a post-transplant pregnancy


Department of Nephrology, St. Martha's Hospital, Bengaluru, Karnataka, India

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Date of Web Publication28-Nov-2016
 

How to cite this article:
Nayak-Rao S. Obstructive nephropathy in a post-transplant pregnancy. Saudi J Kidney Dis Transpl 2016;27:1290-2

How to cite this URL:
Nayak-Rao S. Obstructive nephropathy in a post-transplant pregnancy. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Aug 4];27:1290-2. Available from: http://www.sjkdt.org/text.asp?2016/27/6/1290/194698
To the Editor,

Pregnancy after renal transplantation is a high-risk venture and may be complicated by superimposed preeclampsia, low fetal birth weight, and occasionally graft dysfunction, which may continue postpartum and may compromise long-term graft function. Moreover, the graft is susceptible to the normal physiological changes that occur during pregnancy including ureteral dilatation and hydronephrosis. Acute rejection has been considered rare during pregnancy due to the fact that pregnancy is an immunomodulatory state. We present a patient who presented during pregnancy after kidney transplantation with a unique combination of obstructive nephropathy and acute rejection which responded to appropriate therapy.

A 37-year-old female with native kidney disease of vesicoureteric reflux and reflux nephropathy underwent a pre-emptive kidney transplant, her mother being the donor, in 2008. Her immediate post-transplant course was unremarkable and serum creatinine steadily dropped to 1.3 by the 7 th post-operative day. She did not receive any induction therapy and was maintained on triple immunosuppression with prednisolone, tacrolimus, and mycophenolate mofetil (MMF). She did not have any episode of acute rejection; however, the post-transplant course had been complicated by several episodes of lower urinary tract infections (UTIs) and she was on urinary prophylaxis with Bactrim. All episodes had been due to Escherichia coli and responded to conventional antibiotics. Her previous obstetric history revealed a medical termination of pregnancy six years before and this had occurred before transplantation. She decided to conceive two years after transplant and in accordance MMF was changed to azathioprine at 2 mg/kg. At the time of conception in 2010, her serum creatinine was between 1.0 and 1.2 mg/dL, she required methyl dopa and labetalol for blood pressure control, and a previous 24 h protein done three months before confirmation of pregnancy had revealed 320 mg of protein. At 20 weeks gestation, her serum creatinine suddenly jumped to 1.7 mg/dL and she was admitted for evaluation. An ultrasound of the graft revealed new-onset hydronephrosis to the level of the ureteropelvic junction. Doppler of the graft renal artery and vein were normal. A urine culture done at this time was negative and she was discharged with advice to followup with serial creatinine in the transplant clinic. At 27 weeks, she was admitted to the transplant unit when serum creatinine had jumped to 6.2 mg/dL and the renal ultrasound showed worsening hydronephrosis. She also had a UTI with E. coli; however, she was asymptomatic. She was also appreciating good fetal movements. The exact reason for hydronephrosis could not be ascertained, and a percutaneous nephrostomy tube was inserted into the renal pelvis under ultrasound guidance. She also received intravenous cephalexin as treatment of UTI. With renal functions still rising and the serum creatinine at 6.8 mg/dL, a graft biopsy was done after pre-biopsy hemodialysis (HD). She continued to be afebrile and non-oliguric. The biopsy was consistent with acute rejection 1 b (Banff criteria), and she received 3 doses of methyl prednisolone. After 10 days of HD, serum creatinine had come down to 2.0 mg/dL and she was taken off dialysis. She continued to have good urine output through the nephrostomy tube and otherwise. The nephrostomy tube was changed every four weeks till induction of labor at 37 weeks. She delivered a live baby weighing 2.1 kg after failed induction and emergency cesarean section done for fetal distress.

Urinary tract dilatation has been seen to occur quite frequently during pregnancy most often in the second and third trimester of pregnancy. [1],[2] The occurrence has been reported as high as 70%. These physiological dilatations occur as a result of 40%-50% increase in glomerular filtration rate during pregnancy, progesterone mediated relaxation of the urinary tract, as well as compression of the ureter between the gravid uterus and the pelvic brim. Dilatation is more often right sided but may occur bilaterally. Pregnancy after renal transplantation confers the graft in the right iliac fossa, and the graft ureter can be mechanically compressed by the gravid uterus as it expands. [3],[4] About two-third of women after kidney transplant develop mild to moderate hydronephrosis in the later stages of pregnancy. However, impairment of graft function due to hydronephrosis is rare and mechanical obstruction should be considered in any patient who has severe hydronephrosis at any time during pregnancy or moderate dilatation in the first/second trimester. [5] The occurrence of acute rejection is reportedly rare during pregnancy after renal transplantation due to the fact that pregnancy is an immunomodulatory state. Most pregnancy surveys after transplantation have not been reported acute rejection as a complication occurring in pregnancy. [6],[7] In our patient, the occurrence of acute rejection as a cause of persistent graft dysfunction even after the obstruction was cleared was due to concomitant presence of acute rejection, and this responded quickly to bolus steroids. To the best of our knowledge, this is the first reported case of acute rejection along with urinary tract obstruction in a pregnant patient.

Percutaneous nephrostomy or ureteral stenting [8],[9] have been considered for these patients; however, both involve radiation exposure and hence ultrasound guidance has been used instead especially for percutaneous nephrostomy. Risks of procedure also involve ascending pyelonephritis, premature labor and sometimes ureteral perforation. In our patient, the serum creatinine returned to 1.8 mg/dL after delivery though it did not return to her prepregnancy level. No further hydronephrosis was detected and she continues to be on regular follow-up.

Conflict of interest: None declared

 
   References Top

1.
Rasmussen PE, Nielsen FR. Hydronephrosis during pregnancy: A literature survey. Eur J Obstet Gynecol Reprod Biol 1988;27:249-59.  Back to cited text no. 1
    
2.
Saito K, Suzuki K, Yamagishi T, et al. Hydronephrosis in the early stage of pregnancy after renal transplantation. Int J Urol 2006;13: 809-10.  Back to cited text no. 2
    
3.
Mark PB, McCrea IV, Baxter G, McMillan MA. Hydronephrosis in a pregnant renal transplant patient. Transplant Proc 2009;41:3962-3.  Back to cited text no. 3
    
4.
Levine B, Filly RA, Graber M. The sonographic appearance of renal transplants during pregnancy. J Ultrasound Med 1995;14:291-4.  Back to cited text no. 4
    
5.
Rocha A, Cardoso A, Malheiro J, et al. Pregnancy after kidney transplantation: Graft, mother, and newborn complications. Transplantation 2013; 45:1088-91.  Back to cited text no. 5
    
6.
López V, Martínez D, Viñolo C, et al. Pregnancy in kidney transplant recipients: Effects on mother and newborn. Transplant Proc 2011;43: 2177-8.  Back to cited text no. 6
    
7.
Van Sonnenberg E, Casola G, Talner LB, Wittich GR, Varney RR, D'Agostino HB. Symptomatic renal obstruction or urosepsis during pregnancy: Treatment by sonographically guided percutaneous nephrostomy. AJR Am J Roentgenol 1992;158:91-4.  Back to cited text no. 7
    
8.
Delakas D, Karyotis I, Loumbakis P, Daskalopoulos G, Kazanis J, Cranidis A. Ureteral drainage by double-J-catheters during pregnancy. Clin Exp Obstet Gynecol 2000;27: 200-2.  Back to cited text no. 8
    
9.
Fabrizio MD, Gray DS, Feld KI, Bagley DH. Placement of ureteral stents in pregnancy using ultrasound guidance. Tech Urol 1996;2:121-5.  Back to cited text no. 9
    

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Correspondence Address:
Shobhana Nayak-Rao
Department of Nephrology, St. Martha's Hospital, Bengaluru, Karnataka
India
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DOI: 10.4103/1319-2442.194698

PMID: 27900986

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