Table 2.

Commonly needed drugs in pregnant patients with kidney transplantation

(modified from reference [9])

Drug	Anti-hypertensives	FDA rating
Usually considered first choice
Alpha-methyl dopa	Widely used, with no reported negative effects on the foetus or on its subsequent development. May not be able to correct severe hypertension	B
Niphedipine	The long-acting drug most commonly used in pregnancy. The increase in peripheral oedema may be a relevant side effect in CKD patients	C
Labetalole	Usually well tolerated, should be avoided in subjects with asthma. In a RCT it was shown to be comparable to alpha-methyldopa	C
Usually considered second choice
Beta blockers	The main drawback was foetal growth restriction. Atenolol (D) often involved. May be effective in severe hypertension. May induce hypoglycaemia, hypotension and bradycardia at delivery	B Pindolol C Metoprolol D Atenolol
Clonidine	Side effects and rebounds at discontinuation are common. Slowing foetal growth also reported	C
Alpha blockers	Other drugs should be preferred since controlled studies are missing	C
Diuretics	Usually avoided. Thiazides may be continued. Amiloride may be employed in Gitelman syndrome	B Hydrochlorothiazide Amiloride
To be avoided
Short-acting niphedipine	Contraindicated by FDA, RCOG and AIPE due to the risk of severe sudden hypotension with detrimental effects on placental flows	D
ACEi ARBs	Risk of major malformations, in particular in the second and third trimester	C 1st trimester D 2nd 3rd trimester

FDA rating: A, controlled human studies show no risk; B, no evidence of risk in studies; C, risk cannot be ruled out; D, positive evidence of risk; X, contraindicated in pregnancy

RCOG Royal College of Obstetricians and Gynaecologists, AIPE Associazione Italiana Preeclampsia, ACEi angiotensin-converting enzyme inhibitors, ARBs angiotensin II receptor blockers. For other abbreviations, see Table 1