La tunisie Medicale - 2014 ; Vol 92 ( n°08 ) : 523-526
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Prérequis: La maternité a longtemps été déconseillée chez la femme transplantée rénale par peur des effets délétères sur le greffon et les risques encourus par le fœtus.

But : Répondre de façon factuelle aux questions relatives à la grossesse chez les femmes transplantées rénales: 1. quels sont les paramètres néphrologiques et obstétricaux qui peuvent influencer le déroulement de la grossesse? 2. Quel est l'impact de la grossesse sur le greffon? 3. Quelles sont les conditions optimales pour planifier une grossesse chez les femmes transplantées rénales? Méthodes: Une recherche a été effectuée en utilisant les mots clés "grossesse", "transplantation rénale", "la survie du greffon rénal" sur PubMed au cours de la période allant de Janvier 1994 à Décembre 2011.

Résultats: Le rétablissement de la fonction rénale chez les patientes transplantées rénales est suivi du rétablissement des fonctions endocriniennes. La connaissance de la néphropathie initiale permet d’évaluer le risque de récidive après la transplantation, pouvant toucher le greffon pendant la grossesse. Les néphropathies glomérulaires chroniques sont les plus fréquentes de 32 à 76,1 %. L’ancienneté en hémodialyse (supérieure à 2 ans) est corrélée à un risque d’accouchement prématuré et de retard de croissance. Un délai entre transplantation rénale et conception de 1 an semble raisonnable pour stabiliser la fonction rénale et réduire les doses des immunosuppresseurs. Le nombre de grossesses non planifiées reste élevé (50%). La fréquence des grossesses après la transplantation rénale varie entre 3 et 21,2 %. La survie du greffon chez les patientes ayant mené une grossesse est équivalente à celle des patientes qui n’ont pas été enceintes.

Conclusion : La grossesse chez les patientes transplantées du rein est une grossesse à haut risque, mais elle ne semble pas altérer la fonction du greffon sous réserve de certaines conditions.

Mots Clés

Kidney transplantation is undoubtedly a turning point in the lives of patients suffering from renal failure. In addition to improving the quality of life and prognosis, it is a legitimate hope for all those who want to conceive. Recovery of renal function is followed by the restoration of endocrine function allowing pregnancy. Motherhood has long been not recommended for kidney transplanted women by fear of deleterious effects on graft. Nowadays, under certain conditions, pregnancy in kidney graft is possible. This article aimed to provide evidence based answer to the following questions regarding pregnancy in kidney transplanted women:
1. what are the nephrologic and obstetrical parameters that can influence the pregnancy outcome?
2. What is the impact of pregnancy on graft? 3. What are the optimal conditions for pregnancy planning in kidney transplanted women?


A literature search was conducted using as key words “pregnancy”, “renal transplant”, “renal graft survival” in the PubMed database over the period from January 1994 to December 2011, by taking as language of publication French and English. We retained the original articles, reviews and reports of national transplantation registers. Editorials and abstracts were excluded. All selected articles were analyzed qualitatively. By introducing the key words “pregnancy”, “renal transplant”, “renal graft survival” on the Pubmed database, we obtained 244 publications. Only 31 articles match the eligibility criteria mentioned above and were used in this work.


Nephrological parameters
Chronic glomerular nephropathies (CGN) are recognized in many studies as the most common cause of kidney failure at the origin of the development of chronic hemodialysis in transplanted kidney patients and in whom pregnancy occurred after transplantation. CGN rate was 39.6% in a study by Gill et al. [1], 32% in a study by Areia et al. [2], 52% in a study by Kim et al. [3], 76.1% in a study by Kurata et al. [4], 58.8% in a study by Yildrim et al. [5], 41% in a study by Ehrich et al. [6] and 43.6% in study Rahamimov et al. [7]. The identification of the initial nephropathy is necessary to assess risk of recurrence after transplantation, risk for the graft during pregnancy, or a risk of recurrence in the offspring [8,9]. It does not seem to be useful for predicting the occurrence of pregnancy in a patient who received a kidney transplant [2,3]. A study conducted in 2009 [1] concluded that patients who had renal failure as a result of diabetes were less likely to conceive than those whose initial nephropathy was CGN. In most studies [5-8], the duration of the dialysis before transplantation has not been evaluated. Long standing hemodialysis correlates with accelerated atherogenesis and is associated with a risk of preterm delivery, growth retardation and fetal distress. Kurata found that duration of hemodialysis to transplantation superior to 2 years was related to the occurrence of preterm delivery less than 35 weeks. But this parameter was not found as significant factor of preterm delivery [4]. Gill found no significant association between length of dialysis and the probability to conceive. The decrease in the rate of pregnancy among kidney transplant was explained by the wider use of immunosuppressant drugs including cyclosporine in the treatment of CGN prior to renal transplantation [1]. Kidney transplantation is the best treatment for end-stage renal disease. Patients who benefited from a kidney transplant have a longer life, better quality of life and consume fewer health care resources than patients on chronic dialysis [10-12]. The mean age at transplantation ranged from 23.6 years to 33.4 years, according to studies [1, 3, 7, 8]. The data analysis of the study by Kim and al concluded that younger age at transplantation was a significant predictor for a positive result in the birth of a living child [3].

Parameters related to pregnancy
Planning, a crucial step, as well as monitoring the pregnancy are the result of close collaboration between the obstetrician and the nephrologist. In general, women at the age of procreation are informed of their possibility of conception and recommended for adequate contraception. If pregnancy is desired, the patient is assessed for renal function with stabilization of associated diseases: high blood pressure equilibration, equilibration of diabetes, treatment of infection. The number of unintended pregnancies remains high (about 50%) in several studies [5, 13-15]. A retrospective study by Keitel (2004) about 44 pregnancies occurred in 41 patients, concluded that pregnancy did not affect the survival of the patient and long-term graft while only 5 pregnancies were conducted in the absence of risk factor [13]. Several studies have recommended waiting a period of 2 years after transplantation before allowing patients to conceive [5,7,15,15-19]. In a recent study, Gorgulu reported that a longer period between renal transplantation and conception is related with a lower rate of premature babies and children born with low birth weight [16]. This attitude was considered too conservative by a study conducted in 2009 by Gill about 530 pregnancies in 483 renal transplanted patients [1]. His findings support current recommendations regarding the timing of pregnancy after transplantation, including the suggestion that a 2-year waiting period between transplantation and attempts at conception may be overly conservative.
Kim have recently (2008) concluded that a delay Kidney Transplantation-Conception less than or equal to 1 year was not associated with a higher risk of complications compared with a group of patients whose waiting time before pregnancy was more than one year [3]. Although an optimal interval between transplantation and the design has not yet been established, the National Transplantation Pregnancy Registry (NTPR) and the American Society of Transplantation (AST) suggested waiting 1 year after transplantation, this delay is reasonable to stabilize the renal function and reduce the doses of immunosuppressive drugs [20, 21]. The incidence of pregnancy after renal transplantation has varied from one study to another. Ghanem reported a rate of 21.2% (Of 193 patients of childbearing age, 41 had at least one pregnancy) [19]. In the study by Kim, only 10% of patients of childbearing age have a pregnancy [3] and the rate was even lower in the study by Gill less than 3% (483 of 1619) [1]. The live birth rates ranged from 55.4% to 90% [1,3,5,14,18,19,22].

Complications during pregnancy

The incidence of hypertension among patients transplanted kidney varies from 60% to 80% [23]. Several factors are involved in the onset of hypertension after renal transplantation: immunosuppressive therapy including corticosteroids and cyclosporine, graft function, the nature of the donor, obesity, alcohol, smoking, presence of a native kidney (increased production of renin) [23,24]. The diagnosis of preeclampsia can be difficult due to the frequency of hypertension and proteinuria in kidney transplanted patients [25-27]. Yidirim et al. reported in their study that 15% of patients are worsening hypertension without preeclampsia [5]. Elevation of blood pressure and taking antihypertensive were significantly associated with risk of premature delivery and low birth weight [22]. During pregnancy, the ureter compressed by the gravid uterus expands [27]. The risk of acute pyelonephritis is particularly increased especially in immunodepressed patients. Cruz Lemini [14] reported a frequency of 45.3% urinary tract infections in agreement with that reported by Davison and Milne 40% [9]. The gestational diabetes is a complication even more common with the use of steroids but also of cyclosporine and tacrolimus, gestational diabetes was found in a frequency of 5% to 29.3% [5,14,19].

Delivery and newborn
In most studies, the term at delivery ranged from 35.6 ± 0.3 to 38 weeks of gestation [3,5,17]. Premature rupture of membranes (PROM) was noted in 11% to 17%. It has often been responsible for caesarean section [14, 22]. The preterm birth rate was high in this population estimated at 45-60% of cases [25]. In literature, the rate of premature births found by Yildirim et al is one of the lowest observed (31.25%) (5). This is related to compliance with international recommendations and the fact that patients had a serum creatinine less than 125 µmol / l before conception. The cesarean rate ranges from 40% to 100%, is probably not justified solely by obstetric indications [2,14,18,19,22]. Low birth weight was reported by Sibanda and Ducarme respectively 54% and 40% [18,19]. Intrauterine growth retardation is associated with the use of cyclosporine and prematurity [25].

Long-term follow-up
Most studies have shown that graft survival in patients who had a pregnancy was equivalent to that of patients who were not pregnant [7,28,29]. The NTPR (National Transplantation Pregnancy Registry) found that graft loss in patients who had a pregnancy fluctuated between 4% and 14% within two years after delivery. These rates are similar to those observed in renal transplant who were not pregnant [30]. Data on children from these special pregnancies are reassuring. Nulman compared 39 children exposed in utero to cyclosporine in kidney transplanted patients with a control group of 38 children. No significant differences were found in neurocognitive and behavioral development [31]


Renal transplantation allows patients suffering from end-stage renal disease improving quality of life and represents a legitimate hope for all those who want to conceive. Pregnancy in kidney transplanted patients is a high risk pregnancy because of the higher incidence of low birth weight, prematurity and intrauterine growth retardation. A favorable outcome of pregnancy and the preservation of renal graft is possible through: planning pregnancy (stable renal function and hypertension balanced), monitoring conducted in coordination with the gynecologist and the nephrologist and childbirth in a maternity of 3rd level. For a better understanding of the particularities of pregnancy in kidney transplanted patients in Tunisia, the establishment of a national registry collecting information from all centers of kidney transplant, all services of Gynecology and Obstetrics and free practice physicians is necessary

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