Editorial

Because I have spent most of my career in the Veterans Administration, although always in association with one or more academic affiliates, one might think that I would not have much experience with pregnant transplant and chronic kidney (CKD) disease patients. However, the first few years that I was at the St. Louis Veterans Administration Hospital, the St. Louis University Transplant Program was based at the VA Hospital, and we transplanted nonveterans as well as veterans. In addition, for a number of years I attended as a nephrologist at St. Louis University Hospital. St. Louis University did not have an obstetrics service. Pregnant CKD and transplant patients were cared for at St. Mary’s Hospital in Clayton, Missouri. After a number of instances of requesting emergency privileges at St. Mary’s to care for complicated pregnant transplant patients (usually after 5:00 pm on a Friday afternoon, when the hospital CEO was on the golf course), I requested and was granted permanent privileges. I wish I could have referred to this issue of Advances in Chronic Kidney Disease as a resource to help care for those patients. I frequently felt as if I were flying blind. I purchased two books: Medical Complications during Pregnancy by Burrow and Ferris1 and Drugs in Pregnancy and Lactation by Briggs, Freeman, and Yaffe.2 Although somewhat helpful, these texts left many unanswered questions, and treatment plans were often developed without well-defined guidance and many times with severe underlying anxiety on my part.

Several patients, in particular, stand out in my memory. The first, when I was a fellow, was a 12-year-old or 13-year-old girl who received a successful kidney transplant from one of her parents. Because of her chronic kidney disease, she was short and slight and appeared much younger than her chronologic age. No one thought to counsel her regarding fertility; she returned for follow-up 2 months later pregnant. After that we counseled everyone! The second patient, while I was a fairly junior attending, was the pregnant wife of a medical student who presented comatose with malignant hypertension. She had experienced acute glomerulonephritis as a child and unrecognized chronic kidney disease before pregnancy. Fortunately, we were able to control her hypertension, but she lost the fetus. I was grateful that we did not lose her. She desperately wanted to become pregnant again but progressed to end-stage renal disease and dialysis very rapidly. The third patient received a kidney from her father at 16 years of age. The transplant was successful. She went on to graduate from college and graduate school, and I got to dance at her wedding! Her underlying kidney disease was systemic lupus erythematosus. Because of the drugs she received as a child she was supposed to be infertile, but she became pregnant. The pregnancy was very complicated, one of my emergency privileges at St. Mary’s patients. I walked into her hospital room for afternoon rounds as she spontaneously delivered an Apgar 9 daughter at 32 weeks. I attended the baby’s christening and can tell you she is now a normal, delightful, vivacious teenager—moments like those are what keep you going.

Many years have passed since I have cared for a pregnant transplant patient, but I can still recall the dry mouth and terror when we had no rules to follow. Kudos to Dr. Holley and her authors for providing such wonderful guidance.