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E-Poster Submission Deadline
Please prepare and upload your E-Poster no later than March 14, 2026 11.59PM CET. After this date, you will no longer be able to prepare and upload your E-poster and it will not be displayed and accessible on the congress website.
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Pregnancy after kidney transplantation presents significant clinical challenges, primarily concerning the management of immunosuppression and the risk of graft rejection. This case illustrates a successful obstetric outcome complicated by the emergence of donor-specific antibodies (DSA) and a severe, delayed postpartum rejection episode.
A 32-year-old Sri Lankan female, 4 years and 8 months post-living donor renal transplant, following chronic interstitial nephritis, conceived spontaneously. Pre-pregnancy graft function was stable (creatinine 0.9-1.12 mg/dL) on stable dose of tacrolimus and prednisolone, she had well-controlled blood pressure and no proteinuria. Antenatal care involved close therapeutic drug monitoring. The clinical timeline and key parameters are summarized below:
Timeline
Tacrolimus (Level/Dose)
Donor Specific Antibodies
(MFI)
Creatinine (mg/dL)
Key Event
7 wks Pregnant
4.9 ng/mL / 3mg BD
Not Detected
0.98
Stable
22-27 wks Pregnant
<2 ng/mL / 3.5mg BD
Class I: 4200, Class II: 2200
1.10
Tacrolimus dose increased
31 wks Pregnant
-
DR53: 3341, DRB1*07: 918
De Novo DSA detected
Delivery (35+4 wks)
5.5 ng/mL/ 3.5mg BD
1.25
Healthy infant (2.72kg)
3 months Postpartum
4.9 ng/mL/
SR 7mg m
1.04
Stable Gr
15 mos Postpartum
6.5 ng/mL/
SR 3mg m
DR53: >6500
Elevated
Antibody-Mediated Rejection
An elective cesarean section at 35 weeks and 4 days delivered a healthy male infant. Over the subsequent 18 months, the patient experienced recurrent urinary tract infections. At 15 months post-delivery, she presented with graft dysfunction and was diagnosed with antibody-mediated rejection (ABMR) on biopsy. Treatment involved five cycles of therapeutic plasma exchange (TPE) with low-dose IVIg (10g/dose). Due to persistent high DSA levels, a further five cycles of TPE were performed with high-dose IVIg (70g/dose), followed by Rituximab (700mg x 2 doses, 14 days apart). Post-rituximab, her CD 19+ count was 297.9 cells/μL and had neutropenia (managed with GM-CSF). Mycophenolate mofetil (MMF) was reintroduced during this second round, but DSA (particularly DR53) remained elevated (>6500 MFI). Eight months later, she received two additional 1g doses of Rituximab. Due to persistently elevated DSA, she subsequently received 15 monthly cycles of IVIg (30g/dose), which reduced DSA levels to 3500-4000 MFI and stabilized the creatinine.
This case highlights pregnancy’s role as an immune adjuvant, breaking pre-existing graft tolerance and triggering anamnestic B-cell responses against donor HLA, causing DSA production, culminating in post-partum ABMR. Despite these challenges, graft function was stabilized with creatinine 1.2 mg/dL at 14 years post-transplant on a quadruple-drug regimen : prednisolone 10mg/d, Tacrolimus 3 mg BD, MMF 360 mg BD, Everolimus 0.25 mg BD.
This case confirms that successful pregnancy post-transplant is achievable but carries a significant long-term risk of de novo DSA formation leading to severe, delayed rejection. It underscores the necessity of lifelong, multi-disciplinary vigilance. This reality poses a particular challenge in resource-constrained settings, where sustaining the required intensive long-term monitoring demands tailored strategies and heightened awareness.
