Pregnancy Outcomes Following Triple Organ (Small Bowel, Liver, and Pancreas) Transplantation

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Compared to other solid organ transplants, intestinal transplant is relatively novel, and occurrences of successful pregnancies following this procedure are considerably less common. Literature shows only 10 documented cases of successful pregnancy after intestinal transplantation, and to date, only 1 of which was a triple organ (intestine, liver, pancreas) transplant.We present an extremely rare case of successful pregnancy post triple gastrointestinal organ transplant. Case Description/Methods: 20-year-old, 31-week-pregnant woman was evaluated by our Hepatology team for elevated liver enzymes on routine checkup. The patient had a history of small bowel, liver, and pancreas transplant at age 1 due to complicated gastroschisis at birth, and hospitalization from birth to age 4 years. She had no history of rejection and has had an uncomplicated post-transplant course. Prior to pregnancy, immune suppression was maintained with tacrolimus, sirolimus and prednisone. Sirolimus and prednisone were discontinued when the patient became pregnant, with continuation of tacrolimus 5 mg twice a day, with reported medication compliance. Labs showed elevated liver enzymes: aspartate aminotransferase= 275 IU/L, alanine transaminase =228 IU/L, total bilirubin= 1.8 mg/dL, and FK level < 2, despite reported compliance. Ultrasound imaging revealed normal liver transplant and normal directional flow. Virology panel came back negative. Prednisone 10 mg daily was added. The patient then developed acute kidney injury, Cr:1.37, pulmonary edema, and FK went supra-therapeutic reaching 13.7 so it was held at that time. The patient was diagnosed with preeclampsia with severe features and was taken for an uncomplicated C-section. The baby was admitted to pediatric intensive care unit for preterm labor with initial respiratory insufficiency that later improved with no complications, discharged home 3 weeks later.A month later, liver function tests (LFTs) were elevated with concern for rejection. The patient had a low tacrolimus level, reporting she was taking 3 mg daily instead of twice a day. High dose steroid (1 gm solumedrol for 3 days) was given, with improvement of LFTs after 2 doses. Tacrolimus was increased to 3 mg twice a day and sirolimus was restarted. The patient is currently on tacrolimus and sirolimus with normal LFTs. Discussion: Triple gastrointestinal organ transplant procedure is uncommon, and achieving a successful pregnancy afterward is even rarer. Challenges presented by pregnancy is to maintain stability of the graft, prevent infection, ensure good nutritional support and monitor fetal wellbeing and growth (see Table 1).

Volume

119

Issue

10

First Page

S3043

Last Page

S3044

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