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Internal Medicine

Cite as: Archiv EuroMedica. 2026. 16; 4. DOI 10.35630/2026/16/Iss.4.08

Received 15 July 2026;
Accepted 10 August 2026;
Published 16 August 2026

PREGNANCY AFTER KIDNEY TRANSPLANTATION AS A CLINICAL CHALLENGE: A NARRATIVE REVIEW

Maja Witek³ , Izabela Migdał¹ ,
Justyna Polko¹ , Zuzanna Jeziorska¹ ,
Bartosz Szymajda¹ , Tomasz Horodniczy² ,
Zuzanna Galicka¹ , Jakub Artur Czapkiewicz¹ ,
Weronika Kwaśnica⁴ , Katarzyna Raczek⁵

¹ Medical University of Silesia, Katowice, Poland
² Faculty of Medicine, Wroclaw Medical University, Wroclaw, Poland
³ Medical University of Warsaw, Poland
⁴ Poznan University of Medical Sciences, Poznan, Poland
⁵ Wroclaw Medical University, Wroclaw, Poland

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  izabela.migdal14@gmail.com

ABSTRACT

Background

Pregnancy after kidney transplantation has become a realistic reproductive option owing to advances in transplantation, immunosuppressive therapy, and multidisciplinary care. However, kidney transplant recipients remain at increased risk of maternal, fetal, neonatal, and graft related complications, requiring careful preconception assessment and close monitoring throughout pregnancy.

Aims

The aim of this review is to summarize current evidence regarding maternal, fetal, neonatal, and graft related outcomes of pregnancy after kidney transplantation. Particular attention is paid to preconception counseling, immunosuppressive therapy, pregnancy monitoring, multidisciplinary management, and long term maternal, graft, and offspring outcomes.

Materials and Methods

This narrative review was conducted in accordance with the SANRA recommendations. Literature indexed in PubMed and Google Scholar and published between 2019 and July 2026 was analyzed. Clinical guidelines, registry analyses, systematic reviews, meta analyses, observational cohort studies, and retrospective studies were included. Ultimately, forty-three publications were incorporated into the review.

Results

Pregnancy after kidney transplantation is associated with an increased risk of hypertension, preeclampsia, gestational diabetes mellitus, preterm delivery, neonatal complications, and graft related complications. Reported live birth rates range from approximately 70% to 90%, whereas preeclampsia affects 24 to 38% of pregnancies and preterm delivery occurs in 40 to 60% of cases. More favourable outcomes are associated with stable graft function before conception, minimal proteinuria, well controlled blood pressure, absence of recent rejection, and planned pregnancy. Calcineurin inhibitors, azathioprine, and low dose corticosteroids are generally considered compatible with pregnancy, whereas mycophenolate mofetil is contraindicated because of its teratogenic effects.

Conclusions

Pregnancy after kidney transplantation is feasible in carefully selected women with stable graft function. However, the risks of maternal, neonatal, and graft related complications remain higher than in the general population. Successful management requires preconception counseling, adjustment and monitoring of immunosuppressive therapy, and coordinated multidisciplinary care. Evidence regarding long term maternal renal outcomes and developmental outcomes in offspring remains limited.

Keywords: pregnancy after kidney transplantation; maternal outcomes; neonatal outcomes; preeclampsia; transplant medicine; chronic kidney disease.

INTRODUCTION

Kidney transplantation is a surgical procedure involving the implantation of a healthy kidney into a recipient with end-stage kidney disease. Compared with dialysis, transplantation offers improved quality of life and longer survival for affected patients [1,2]. For women of reproductive age, restoration of normal endocrine and reproductive function after transplantation is particularly important [3].

Before the development of modern transplantation and immunosuppressive strategies, pregnancy after transplantation was generally discouraged because it was considered a high-risk condition. Today, owing to advances in transplant medicine, most kidney transplant recipients who become pregnant achieve successful outcomes with favorable maternal and fetal results [4,5].

Despite these advances, pregnancy after kidney transplantation remains a significant clinical challenge. Maternal complications, including hypertension, infections, preeclampsia, gestational diabetes, and deterioration of graft function, occur more frequently among transplant recipients [6,7]. In addition, neonatal complications such as prematurity, low birth weight, and admission to neonatal intensive care units are more common [8,9].

Significance and Novelty

Pregnancy after kidney transplantation requires careful preconception assessment, adjustment of immunosuppressive therapy, and coordinated monitoring of maternal, fetal, and graft health. Current clinical recommendations emphasize pregnancy planning, stable graft function before conception, and multidisciplinary management throughout pregnancy [11,12,15]. However, the available evidence is fragmented across studies of maternal, fetal, neonatal, and graft related outcomes, while data on long term outcomes in offspring remain limited. This review summarizes current evidence in these areas and examines the principal factors associated with favourable pregnancy outcomes.

AIM OF THE REVIEW

The aim of this narrative review is to summarize current evidence regarding maternal, fetal, neonatal, and graft related outcomes of pregnancy after kidney transplantation, with particular emphasis on preconception counseling, immunosuppressive therapy, obstetric complications, pregnancy monitoring, and long term maternal, graft, and offspring outcomes.

Research Questions

This narrative review addresses the following research questions:

1. What maternal, fetal, neonatal, and graft related outcomes are reported in pregnancies after kidney transplantation?
2. Which clinical factors are associated with favorable pregnancy outcomes and preservation of graft function in kidney transplant recipients?
3. How should immunosuppressive therapy be managed before conception, during pregnancy, and during breastfeeding?
4. What recommendations are currently available regarding preconception counseling, pregnancy monitoring, and long term follow up after kidney transplantation?

MATERIALS AND METHODS

This study was designed as a narrative review conducted in accordance with the SANRA (Scale for the Assessment of Narrative Review Articles) recommendations.

A literature search was performed in PubMed and Google Scholar to identify publications addressing pregnancy after kidney transplantation. English language publications published from 2019 and available up to July 2026 were considered. This period was selected to focus the review on recent evidence, current clinical recommendations, and contemporary approaches to the management of pregnancy after kidney transplantation.

The search terms included “kidney transplantation”, “renal transplantation”, “pregnancy”, “maternal outcomes”, “fetal outcomes”, “preeclampsia”, “graft survival”, and “immunosuppressive therapy”.

Inclusion Criteria

1. English-language articles published between 2019 and 2026.
2. Original clinical studies, observational cohort studies, registry analyses, systematic reviews, meta-analyses, and clinical guidelines involving kidney transplant recipients.
3. Studies evaluating maternal, fetal, neonatal, or graft-related outcomes after kidney transplantation.
4. Publications addressing preconception counseling, immunosuppressive therapy, pregnancy management, or long-term outcomes after transplantation.

Exclusion Criteria

1. Non-English-language publications.
2. Studies published before 2019.
3. Case reports with insufficient clinical information.
4. Publications lacking relevant outcome data regarding pregnancy after kidney transplantation.

Following application of the inclusion and exclusion criteria, 43 publications were included in the final narrative synthesis. The evidence was analyzed according to the following thematic domains: restoration of fertility, timing of conception, maternal outcomes, neonatal outcomes, graft function, immunosuppressive therapy, breastfeeding, and long-term outcomes.

The review followed the principles of narrative synthesis described by Popay et al. [43].

RESULTS

Literature Characteristics

The final review included 43 publications comprising systematic reviews, meta-analyses, registry analyses, observational cohort studies, clinical guidelines, and retrospective studies. The included literature focused on maternal complications, neonatal outcomes, graft function, immunosuppressive management, breastfeeding, and long-term follow-up after kidney transplantation.

Restoration of Fertility after Kidney Transplantation

Women with chronic kidney disease (CKD) and end-stage kidney disease (ESKD) often experience disruption of the hypothalamic–pituitary–gonadal axis, resulting in irregular menstruation, anovulation, reduced libido, vaginal dryness, and infertility [13]. Kidney transplantation can restore normal endocrine and reproductive function, with recovery of the hypothalamic–pituitary–gonadal axis often occurring within six months after transplantation [14].

Contraceptive methods are generally considered safe and effective in clinically stable kidney transplant recipients [15].

Timing of Pregnancy after Kidney Transplantation

The American Society of Transplantation, the Italian Society of Nephrology, and Kidney Disease: Improving Global Outcomes (KDIGO) recommend postponing conception for at least one year and preferably two years after transplantation. This delay reduces the risk of graft dysfunction, rejection, infection, and fetal exposure to potentially teratogenic immunosuppressive medications [16].

Optimal conditions before conception include:

• stable serum creatinine levels below 1.5 mg/dL,
• proteinuria below 500 mg/day,
• well-controlled blood pressure,
• absence of recent episodes of acute rejection [17].

Advanced graft dysfunction before pregnancy is associated with an increased risk of maternal complications and graft loss [18].

The recommended clinical criteria that should be fulfilled before conception in women with a kidney transplant are summarized in Table 1.

Maternal, fetal, and graft-related outcomes reported in pregnancies after kidney transplantation are summarized in Table 2.

The characteristics of selected key studies included in the review are summarized in Table 3.

The reviewed studies consistently demonstrated favorable live birth rates among carefully selected kidney transplant recipients, although maternal and neonatal complications remained more frequent than in the general population.

MATERNAL OUTCOMES

Pregnant kidney transplant recipients have an increased risk of maternal complications. Chronic hypertension is reported in up to 50% of cases, while preeclampsia occurs in approximately 24 to 38% of pregnancies. Its diagnosis may be difficult because hypertension and proteinuria may already be present before pregnancy [19].

Preeclampsia is associated with deterioration of renal function, increased serum creatinine levels, a higher risk of preterm delivery, and an increased risk of progression to end stage kidney disease [20,21].

Gestational diabetes mellitus occurs in approximately 16% of pregnancies. This risk may be influenced by the diabetogenic effects of tacrolimus and corticosteroids [22,23].

Therapeutic drug monitoring of tacrolimus and cyclosporine is recommended during pregnancy because physiological changes may alter their blood concentrations [15,31,32]. Asymptomatic bacteriuria and urinary tract infections require prompt treatment [15].

Vaginal delivery is generally possible after kidney transplantation. Cesarean delivery should be performed only when obstetric indications are present [24].

Neonatal Outcomes

Pregnancy after kidney transplantation is associated with an increased risk of neonatal complications. Nevertheless, reported live birth rates range from approximately 70% to 90%. Neonatal mortality has been reported at approximately 1.3%, compared with 0.4% in the general population [25,26].

Maternal hypertension, preeclampsia, and reduced estimated glomerular filtration rate (eGFR) are major risk factors for preterm birth. The average gestational age at delivery is approximately 35 weeks, and the mean birth weight is around 2.5 kg. The incidence of congenital malformations is not significantly increased compared with the general population; however, exposure to teratogenic medications substantially increases the risk of fetal abnormalities [27].

Kidney transplantation itself is not a contraindication to vaginal delivery. Only approximately 8% of newborns have an Apgar score below 5 at one minute after birth, and approximately 14% require admission to a neonatal intensive care unit (NICU). The most common neonatal complications include respiratory distress syndrome and an increased susceptibility to infections [28].

Cytomegalovirus (CMV) infection remains one of the most serious complications after transplantation. Maternal CMV infection may result in congenital malformations or congenital liver disease in more than 10% of affected pregnancies, with the greatest risk occurring during early gestation [21,29].

Available evidence regarding long-term developmental outcomes in children born to kidney transplant recipients is generally reassuring; however, the amount of long-term follow-up data remains limited.

Immunosuppressive Therapy During Pregnancy

Immunosuppressive therapy is essential for maintaining graft function and preventing rejection. Therefore, treatment must be continued throughout pregnancy to ensure both maternal health and graft survival.

The most commonly prescribed immunosuppressive agents include:

• calcineurin inhibitors (cyclosporine and tacrolimus),
• antiproliferative agents (mycophenolate mofetil, azathioprine, and sirolimus),
• corticosteroids.

Mycophenolate mofetil is associated with a significantly increased risk of embryopathy and spontaneous miscarriage. Consequently, women receiving mycophenolate should use effective contraception. The drug should be discontinued and replaced with azathioprine at least six weeks before conception. Azathioprine is considered safer because the fetal liver lacks the enzymes required to convert it into its active metabolites.

Azathioprine, calcineurin inhibitors, and low-dose corticosteroids have not been associated with an increased risk of congenital malformations and are therefore considered compatible with pregnancy [15,21,31].

Physiological changes during pregnancy affect both the pharmacokinetics and pharmacodynamics of many immunosuppressive medications [41]. As a result, regular monitoring of immunosuppressive drug concentrations and appropriate dose adjustments are required throughout gestation.

Delivery and breastfeeding do not generally require discontinuation of immunosuppressive therapy; however, treatment should always be individualized according to the patient's clinical condition and therapeutic regimen [30,31].

Breastfeeding after Kidney Transplantation

Historically, breastfeeding was discouraged in kidney transplant recipients because of concerns regarding infant exposure to immunosuppressive medications through breast milk.

Contemporary evidence suggests that infant exposure to most immunosuppressive drugs through breast milk is considerably lower than fetal exposure during pregnancy and is generally regarded as acceptable [21,32].

As a result, breastfeeding is increasingly encouraged among clinically stable transplant recipients. Appropriate lactation counseling should be provided and should take into account maternal health status, graft function, and the specific immunosuppressive regimen being used [33].

Graft Function and Long-term Outcomes

Pregnancy does not appear to significantly impair long term graft survival in women with stable kidney function before conception.

Poorly controlled hypertension, significant proteinuria, and markedly reduced eGFR before pregnancy are associated with an increased risk of adverse maternal and fetal outcomes and deterioration in graft function [10,34]. Physiological renal adaptations during pregnancy may temporarily alter laboratory parameters. Serum creatinine levels usually decrease during the first trimester, remain relatively stable during the second trimester, and return toward prepregnancy values during the third trimester [15,31]. Failure of serum creatinine to decrease during early pregnancy or a progressive increase in creatinine concentration should prompt further investigation, including renal ultrasound, assessment of proteinuria, donor specific antibody testing, and, in selected cases, allograft biopsy [35].

Acute kidney injury has been reported in up to 14% of pregnancies and requires identification of the underlying cause and individualized management [36].

Preeclampsia is associated with endothelial dysfunction, worsening hypertension, deterioration of renal function, and an increased risk of progression of chronic kidney disease [37].

The clinical manifestations of preeclampsia, including hypertension, increasing proteinuria, and worsening renal function, may overlap with those of acute allograft rejection. This overlap complicates differential diagnosis and may influence clinical management.

Greater graft hyperfiltration capacity, considered a marker of preserved renal functional reserve, has been associated with more favorable pregnancy outcomes and better long term renal function after pregnancy [38].

DISCUSSION

Pregnancy after kidney transplantation has become a realistic reproductive option for women with stable graft function. Successful outcomes depend on careful preconception assessment, adjustment of immunosuppressive therapy, and coordinated obstetric and transplant care.

A multidisciplinary approach involving nephrologists, transplant physicians, obstetricians, and neonatologists is important because the risks of hypertension, preeclampsia, preterm delivery, and graft related complications remain higher than in the general population.

Stable allograft function before conception is one of the principal factors associated with favorable pregnancy outcomes and preservation of long term graft function [39]. Well controlled blood pressure, minimal proteinuria, and the absence of recent rejection further improve the likelihood of a favorable outcome [40].

Preeclampsia remains one of the most frequent maternal complications. Its diagnosis may be difficult because hypertension, proteinuria, and deterioration of renal function may also indicate acute allograft rejection. Careful clinical assessment is therefore required to distinguish these conditions and select appropriate management [42].

Current evidence supports individualized adjustment and monitoring of immunosuppressive therapy throughout pregnancy. However, data on long term maternal renal outcomes and developmental outcomes in offspring remain limited.

Limitations

This narrative review has several limitations. The literature search was restricted to PubMed and Google Scholar, English language publications, and studies published from 2019 to July 2026. The narrative design may also involve subjective selection and interpretation of the available evidence. In addition, most included data originated from cohort studies and registry analyses, while heterogeneity in graft function, immunosuppressive regimens, study populations, and diagnostic criteria limited direct comparisons between studies.

Future research should focus on long term maternal renal outcomes, developmental outcomes in exposed offspring, and optimization of immunosuppressive strategies during pregnancy.

CONCLUSIONS

Pregnancy after kidney transplantation is a feasible reproductive option for carefully selected women. However, the risks of hypertension, preeclampsia, preterm delivery, neonatal complications, and graft dysfunction remain higher than in the general population.

The most favorable outcomes are associated with stable graft function before conception, well controlled blood pressure, minimal proteinuria, absence of recent rejection, and planned pregnancy. Immunosuppressive therapy should be adjusted before conception and monitored throughout pregnancy. Mycophenolate mofetil should be avoided, while pregnancy compatible regimens should be continued when clinically indicated.

Successful management requires preconception counseling and coordinated follow up by nephrologists, transplant specialists, obstetricians, and neonatologists. Available evidence indicates that pregnancy does not substantially impair long term graft survival in women with stable renal function before conception. However, evidence regarding long term maternal renal outcomes and developmental outcomes in offspring remains limited.

DISCLOSURE

Author Contributions

Conceptualization: Maja Witek, Izabela Migdał, Justyna Polko, Jakub Artur Czapkiewicz. Methodology: Maja Witek, Katarzyna Raczek, Zuzanna Jeziorska, Bartosz Szymajda, Weronika Kwaśnica, Tomasz Horodniczy. Data collection: Tomasz Horodniczy, Weronika Kwaśnica, Zuzanna Jeziorska, Zuzanna Galicka. Analysis: Zuzanna Galicka, Bartosz Szymajda, Jakub Artur Czapkiewicz, Zuzanna Jeziorska. Writing: Maja Witek, Justyna Polko, Zuzanna Galicka, Katarzyna Raczek, Izabela Migdał.

The authors approved the final version of the manuscript.

Funding

The authors received no external funding for this study.

Conflict of Interest

The authors declare no conflicts of interest.

Use of Artificial Intelligence

The authors used artificial intelligence (ChatGPT) to improve the linguistic quality and structural organization of the manuscript. All content generated or modified with the assistance of artificial intelligence was carefully reviewed, verified, and approved by the authors, who take full responsibility for the final version of the manuscript.

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