Table 1.
Transplant physician monitoring schemea
| Test/Visit | When/Minimal Interval | Rationale |
|---|---|---|
| Prepregnancy evaluation | ||
| rubella | Before transplantation | A live virus vaccine; do not administer after transplantation |
| RH compatibility of patient and transplant | Before pregnancy | If the patient is RH negative and the kidney is RH positive, then theoretically the patient may become sensitized to RH, which may pose a problem only if the baby is RH positive |
| hepatitis B and C, HSV, CMV, HIV, toxoplasmosis, and rubella | Before pregnancy | Counsel regarding risks before pregnancy and risk for transmission; hepatitis B vaccine can be given; reduce HIV transmission; check cervical cultures if HSV positive |
| Pregnancy evaluation | ||
| BP | Daily | Patient can monitor and report |
| clinic visits | Every 2 to 3 wk up to 20 wk; every 2 wk until 28 wk; every week thereafter | High-risk pregnancy with likelihood of preterm delivery |
| Routine laboratory testing | ||
| pyuria and urine culture | Each visit | Risk for ascending asymptomatic bacteriuria and pyelonephritis |
| CBC | Every 2 to 6 wk | Decreased WBC count may predict neutropenia and thrombocytopenia in the newborn; if anemia is present, then an ESA may be useful if not iron deficient or other reversible causes of anemia are ruled out |
| serum BUN, creatinine, calculated clearance, and proteinuria | Every 2 to 4 wk | Rejection and pre-eclampsia are difficult to diagnose |
| calcium and phosphorous | Monitor at start and as needed | Transplant patients may have tertiary hyperparathyroidism or have had subtotal parathyroidectomy |
| CNI | Every 2 to 4 wk | Levels may vary throughout gestation |
| liver function tests | Every 6 wk | Gravid liver may be more sensitive to azathioprine hepatotoxicity |
| glucose tolerance test | Each trimester | Many patients are taking steroids or CNI |
| Testing specific to pregnancy | ||
| IgM to toxoplasmosis | Each trimester if seronegative | Risk for congenital infection |
| IgM to CMV | Each trimester if seronegative | Risk for congenital infection |
| More invasive testing | ||
| kidney biopsy | Unexplained decrease in allograft function | Hard to appreciate graft dysfunction and to distinguish acute rejection from CNI toxicity, preeclampsia, and pyelonephritis |
a
Adapted from reference (35). BUN, blood urea nitrogen; CBC, complete blood count; CMV, cytomegalovirus; CNI, calcineurin inhibitor; ESA, erythropoiesis-stimulating agent; HSV, herpes simplex virus; WBC, white blood cell.