Francis Tinney Jr, Taneev Escamilla, Rohini Prashar MD, Mariella Ortigosa-Goggins MD, Jerry Yee MD
Introduction: While numerous successful pregnancies in recipients of solid organ transplants have been reported, definitive data on maternal, fetal and graft outcomes is still lacking. We report an interesting case of renal allograft rejection that occurred in a simultaneous pancreas and kidney (SPK) transplant recipient during pregnancy.
Case: We describe a renal graft rejection without pancreatic graft rejection in the third trimester of a previously normal pregnancy in a SPK transplant recipient. A 36-year-old woman with end-stage renal disease, secondary to type 1 diabetes mellitus, had received a SPK transplant four years prior to a planned pregnancy. Two months before pregnancy, mycophenolate mofetil was substituted for azathioprine. Gestation was uneventful until week 32 weeks when the patient developed an acute elevation of serum creatinine (SCr) from 0.8 mg/dL to 3.6 mg/dL, worsening hypertension, and sub-therapeutic tacrolimus level (2.2 ng/ dl). The concern for potential allograft failure prompted urgent induction of labor, in order to conduct a kidney biopsy and modify the immunosuppression regimen. A postpartum renal biopsy demonstrated acute renal graft cellular rejection (Banff 1B). Subsequent treatment with five doses of thymoglobulin led to a decline in SCr to 2.1mg/dL.
Discussion: The National Pregnancy Transplant Registry does not report an increased risk of rejection during pregnancy in kidney-only transplant recipients. Still, there is a paucity of data for graft outcomes in SPK transplant recipients. Our case highlights the high-risk graft rejection period in pregnancy and postpartum. In addition, this case underscores the importance of scrupulous monitoring of tacrolimus levels during pregnancy.