Leveraging the Transplant Pregnancy Registry International, we conducted a retrospective study of children born to liver transplant (LT) recipients between 1986-2023 to evaluate long term health outcomes of offspring. Child data were collected primarily from bi-yearly maternal phone interviews. Descriptive statistics and multivariate analyses were used to evaluate risk factors for adverse child outcomes. There were 599 children with follow-up data, born to 435 LT recipients of whom 73% were white and 13.1% Hispanic with a median age at conception of 29.4 yrs. The most common LT indications were autoimmune hepatitis (14.2%) and biliary atresia (13.9%); Time from LT to delivery was median 6.9 yrs (IQR 3.1, 14.2); 21.0.% of mothers required anti-hypertensives in pregnancy, 20.7% developed preeclampsia, and 46.1% had cesarean delivery. Most (68.3%) children were healthy and developing well at median 7.6 (IQR: 3.3, 14.9) years of follow up. The most common pediatric conditions in offspring were allergies (6.5%), asthma/reactive airway disease (4.7%), attention deficit hyperactivity disorder/ attention deficit disorder (ADHD/ADD) (2.3%), mild developmental delay (2.7%), autism spectrum disorder (2.0%), and mood disorders (1.2%). Most school-age children of LT recipients were healthy overall, without greater risk for growth or cognitive conditions than the general pediatric population.

Solid organ transplantation (SOT) offers people with end-stage organ disease an increased quality of life, which includes the return of fertility and the potential for pregnancy. Although the number of pregnancies has increased, definitive recommendations have been lacking. To address reproductive health in SOT recipients, the American Society of Transplantation Women's Health Community of Practice held a virtual Controversies Conference with subject matter experts gathered to discuss topics of contraception, immunosuppression, and pregnancy in SOT recipients and pregnancy post-living donation. This publication is a synthesis of expert guidance and available data regarding pregnancy management and outcomes after all types of SOTs.

Heart transplant recipients (HTRs) during pregnancy are at greater risk for maternal and obstetrical complications and hypertensive disease of pregnancy exacerbates these risks. The impact of preeclampsia on HTRs is unknown. The authors describe characteristics of HTRs who developed preeclampsia and the effect of preeclampsia on graft and pregnancy outcomes. This is a retrospective group study of adult HTRs with subsequent pregnancy outcomes of ≥20 weeks' gestation enrolled in the Transplant Pregnancy Registry International between 1986 and 2022. The primary outcome was graft loss within 2 years from delivery. Secondary outcomes included maternal and neonatal outcomes. A total of 146 pregnancies and 149 neonates met inclusion criteria. All were livebirths. Forty-two pregnancies (28.8%) were complicated by preeclampsia. HTRs in the preeclampsia group were more likely to be nulliparous (81.0% vs 54.8%; P < 0.01), and have chronic hypertension (73.8% vs 34.6%; P < 0.01). There was no difference in incidence of graft loss at 2 years with (4.8%) or without (2.9%) preeclampsia (P = 0.72). There was no clinically important difference in graft survival in pregnancies with preeclampsia compared with pregnancies without preeclampsia (adjusted HR: 0.79 [95% CI: 0.37-1.69]; P = 0.54). However, rates of severe maternal morbidity were high in both groups: 16.7% in the preeclampsia group and 10.6% in those without preeclampsia. Furthermore, preeclampsia was associated with earlier gestational age at birth (35.0 vs 37.0 weeks; P < 0.01) and lower birth weight (2,310 vs 2,801 grams; P < 0.01). There was no difference in graft loss from delivery in HTRs who developed preeclampsia during pregnancy. Regardless of preeclampsia, pregnant HTRs are more likely than the general population to experience severe maternal morbidity. These findings provide pertinent information for counseling heart transplant recipients who pursue pregnancy.

BACKGROUND:Heart transplant recipients (HTRs) during pregnancy are at greater risk for maternal and obstetrical complications and hypertensive disease of pregnancy exacerbates these risks. The impact of preeclampsia on HTRs is unknown. OBJECTIVES:The authors describe characteristics of HTRs who developed preeclampsia and the effect of preeclampsia on graft and pregnancy outcomes. METHODS:This is a retrospective group study of adult HTRs with subsequent pregnancy outcomes of ≥20 weeks' gestation enrolled in the Transplant Pregnancy Registry International between 1986 and 2022. The primary outcome was graft loss within 2 years from delivery. Secondary outcomes included maternal and neonatal outcomes. RESULTS:A total of 146 pregnancies and 149 neonates met inclusion criteria. All were livebirths. Forty-two pregnancies (28.8%) were complicated by preeclampsia. HTRs in the preeclampsia group were more likely to be nulliparous (81.0% vs 54.8%; P < 0.01), and have chronic hypertension (73.8% vs 34.6%; P < 0.01). There was no difference in incidence of graft loss at 2 years with (4.8%) or without (2.9%) preeclampsia (P = 0.72). There was no clinically important difference in graft survival in pregnancies with preeclampsia compared with pregnancies without preeclampsia (adjusted HR: 0.79 [95% CI: 0.37-1.69]; P = 0.54). However, rates of severe maternal morbidity were high in both groups: 16.7% in the preeclampsia group and 10.6% in those without preeclampsia. Furthermore, preeclampsia was associated with earlier gestational age at birth (35.0 vs 37.0 weeks; P < 0.01) and lower birth weight (2,310 vs 2,801 grams; P < 0.01). CONCLUSIONS:There was no difference in graft loss from delivery in HTRs who developed preeclampsia during pregnancy. Regardless of preeclampsia, pregnant HTRs are more likely than the general population to experience severe maternal morbidity. These findings provide pertinent information for counseling heart transplant recipients who pursue pregnancy.

Background Limited data exist to inform and appropriately counsel female lung transplant (LuT) recipients regarding pregnancy after transplantation. Study Question What are the modifiable factors that impact pregnancy outcomes in female LuT recipients? Study Design and Methods Retrospective observational analysis was performed on female LuT recipients who reported pregnancies after transplantation to the Transplant Pregnancy Registry International (TPRI). Results Fifty-three recipients who underwent LuT from 1991 through 2021 reported 72 pregnancies to TPRI. Predominant indications for transplant were cystic fibrosis (60%) and pulmonary hypertension (19%). Contraceptive use after transplantation was 36%. Most recipients (54%) reported unplanned pregnancies. The live birth rate was 62%, resulting in 46 live births. Approximately 60% of births were premature (< 37 weeks’ gestational age [GA]) and of low birth weight (LBW) (< 2,500 g). Birth defects were seen in 7 children (16%), none with mycophenolic acid (MPA) embryopathy. Three neonatal deaths resulted from extreme prematurity; 43 remaining children are healthy. Twenty recipients (38%) have died a median of 23.6 years after LuT. Recipients with transplant-to-conception interval of ≤ 2 years had no difference in mortality compared with those with transplant-to-conception interval of > 2 years (hazard ratio [HR], 1.26; 95% CI, 0.50-3.12; P = .625). Recipients whose first pregnancy after transplantation was unplanned showed lower survival (HR, 7.02; 95% CI, 1.35-36.45; P = .020). Newborns of LuT recipients with planned vs unplanned pregnancies had higher median GA (36.9 weeks vs 34 weeks; P = .025) and birth weight (2,639 g vs 2,155 g; P = .047), and significantly lower risk of LBW for singletons (OR, 0.26; 95% CI, 0.07-0.94; P = .036). Interpretation Successful pregnancy after LuT is achievable, however, not without risks for mother and offspring. Our results showed that planned pregnancies resulted in higher GA and birth weight live births and showed lower mortality after pregnancy. TPRI data show 54% of recipients reported unplanned pregnancies, an obvious area for improvement. Planning pregnancy is the most modifiable factor for mitigating risks.

ObjectiveTo evaluate the trends, safety, and feasibility of a trial of labor after cesarean (TOLAC) among kidney and liver transplant recipients.MethodsThis was a retrospective cohort study using the Transplant Pregnancy Registry International. It included recipients of a kidney or liver transplant with a live-birth pregnancy >= 20 weeks following a prior cesarean, with births between 1967 and 2019 from 289 hospitals, primarily in North America. The primary outcomes of severe maternal morbidity (SMM) and neonatal composite morbidity were compared between those with repeat cesarean deliveries (RCDs), vaginal births after cesarean (VBACs), and failed TOLAC. Multivariable regression was conducted to calculate odds ratios and 95% confidence intervals.ResultsThe 243 deliveries included in this study were composed of 80.7% RCDs, 10.3% VBACs, and 9.1% with failed TOLAC, with similar demographics between groups. There was no significant difference in incidence of SMM (RCD, 1.0%; VBAC, 4.0%; failed TOLAC, 0%; P = 0.48) or neonatal composite morbidity (RCD, 15.2%; VBAC, 11.5%; failed TOLAC, 4.5%; P = 0.45) between groups. No cases of uterine rupture or neonatal death occurred. Trends in TOLAC demonstrate that the TOLAC rate has declined from 35% in 1989-1994 to 13% in 2014-2019.ConclusionsIn this cohort of transplant recipients, TOLAC resulted in successful vaginal delivery over half the time, and did not increase the risk of maternal or neonatal morbidity compared with RCD. We encourage offering transplant recipients a trial of labor after appropriate counseling to decrease the overall rate of cesarean delivery and morbidity in this high-risk population.

In female transplant recipients, immunosuppressant use during pregnancy raises potential concerns about adverse maternal and fetal outcomes. This noninterventional study used prospectively and retrospectively reported cases from the Transplant Pregnancy Registry International database from 1991 until 2020. The study used 2 separate cohorts to evaluate the prevalence of major malformations and small for gestational age (SGA), respectively, among live-born infants of female kidney or liver transplant recipients receiving tacrolimus-containing regimens (Tac) or non-tacrolimus-containing regimens (non-Tac). There were 1988 pregnancies (2056 livebirths) in the cohort used to assess the prevalence of malformations and 2172 pregnancies (2248 livebirths) in the cohort used to assess the prevalence of SGA. Prevalence of major malformations was similar in Tac and non-Tac groups: 2.0% and 1.9% in prospectively reported cases, and 4.7% and 3.1% in retrospectively reported cases, respectively (overall adjusted odds ratio, 1.10; 95% confidence interval, 0.68, 1.81). There was a lower prevalence of SGA in the Tac group than in the non-Tac group: 17.9% and 32.2% in prospectively reported cases and 18.1% and 23.5% in retrospectively reported cases, respectively (overall odds ratio, 0.70; 95% confidence interval, 0.57, 0.87). The use of tacrolimus in female transplant recipients was not associated with a high risk of major malformations or SGA in live-born infants.

Lack of data regarding pregnancy post-kidney transplantation challenges clinicians who are faced with complex, high-risk cases. Aiming at tackling knowledge gaps and limited cross-cultural data on pregnancy in kidney transplant recipients (KTRs), we compared the methodologies and pregnancy outcomes of three registries based in three continents. Data were gathered from reports and publications of the Pregnancy After Renal Transplantation OUTcomes registry (PARTOUT, Netherlands), the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), and the Transplant Pregnancy Registry International (TPRI, United States of America and international). We targeted the similarities and differences among the registries to understand methodological variations. The registries utilized distinct approaches regarding data collection which influence data interpretation. PARTOUT conducted a retrospective analysis of all Dutch pregnant KTRs between 1971 and 2017. ANZDATA includes annual surveys on all KTR parenthood events since 1968. TPRI offers international coverage and includes pregnant KTRs voluntarily registered since 1991. Despite methodological differences, preeclampsia, preterm birth and low birth weight were common pregnancy complications, and outcomes were mostly comparable among the registries. Despite differences in case capture, the three registries reported similar pregnancy and newborn outcomes, confirming that pregnancy in KTRs can be successful with careful monitoring across varying populations. Identifying the strengths and weaknesses of each registry can contribute to improved methodologies for global data collection and lower missing data rates. Although managing large databases may be challenging, aligning data across countries could lead to meaningful data pooling, while identifying drivers of outcomes across subpopulations.

Preeclampsia affects ≥ 25% of kidney transplant recipients during pregnancy, but its impact on longitudinal graft survival are unclear. We aim to characterize longitudinal graft survival from the time of delivery and investigate maternal and neonatal outcomes in kidney transplant recipients who experienced preeclampsia. Retrospective cohort study of kidney transplant recipients enrolled in an international transplant registry with a pregnancy of ≥ 20 weeks’ gestation between 1967-2019. Primary outcome was graft loss after delivery. Secondary outcomes included severe maternal and neonatal composite morbidity. Univariate, Kaplan-Meier curves, and Cox proportional-hazards models were constructed for statistical analysis using Rstudio v.2023.06.1. There were 2,106 kidney transplant recipients, of which 1,574 pregnancies and 1,641 neonates met inclusion criteria. Preeclampsia was reported in 447 (28.4%) of pregnancies. Recipients with preeclampsia were more likely to be nulliparous, self-identify as white, report tacrolimus use during pregnancy, have cesarean births, and have a multiple gestation. Preeclampsia was associated with higher creatinine during pregnancy (p< 0.01) and after pregnancy (p=0.02), but there was no difference in pre-pregnancy creatinine (p=0.80). Severe maternal morbidity was higher in those with preeclampsia (4.7% vs 2.5%, p=0.02). Preeclampsia was associated with higher neonatal composite morbidity (23.5% vs 9.6%, p< 0.01), as well as higher rates of NICU stays (33% vs 16%, p< 0.01). Preeclampsia was associated with a shorter interval to graft loss after delivery (8.9, vs 14.4 years, p< 0.01); however, on survival analysis there was no increased risk of graft loss from delivery (aHR: 1.22, [0.99, 1.49]) after adjusting for covariates. In kidney transplant recipients who developed preeclampsia during pregnancy, a shorter time to graft loss and increased severe maternal and neonatal composite morbidity was observed. There was no difference in kidney graft survival based on a history of preeclampsia in a post-transplant pregnancy.

We report on living kidney donation from a prison inmate on death row. Thirty years ago, we were involved in an unusual set of circumstances that we assumed would never arise again. That assumption is incorrect as a current death row inmate wishes to be a living kidney donor and we speak now to describe the lessons learned and to help others. This report is focused on living donation, excluding posthumous donation, and discusses the ethical, legal, medical, and logistic considerations underpinning prisoner donation for both the general prison population and death row inmates. We believe inmates on death row can be considered as living organ donors and the ethical, logistic, and medical hurdles surmounted to enable donation. This experience with death row inmates should serve to encourage donations from the general prison population.