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Background <p>Pregnancy after renal transplantation is increasingly encountered due to improved graft survival and safer immunosuppressive regimens. These pregnancies remain high-risk, with substantial maternal and fetal morbidity. Distinguishing severe preeclampsia from acute graft rejection poses a major diagnostic challenge, as both conditions share overlapping clinical features. This report highlights such a dilemma in the management of a renal transplant recipient with deteriorating renal parameters and hypertension in the late second trimester.</p> Case <p>A 29-year-old multigravida, a live donor renal transplant recipient with history of earlyonset severe preeclampsia and early neonatal loss conceived spontaneously. In current pregnancy, initial antenatal evaluation revealed stable graft function and normal aneuploidy screening. At 29&#xa0;weeks, she developed severe hypertension, worsening proteinuria, rising creatinine, fetal growth restriction, and a culture-positive urinary tract infection. Despite intensified antihypertensive therapy, renal parameters continued to decline. The sFlt-1/PLGF ratio was borderline (84.5), leaving diagnostic uncertainty regarding preeclampsia versus acute graft rejection. An ultrasound-guided renal graft biopsy was performed, demonstrating interstitial fibrosis and tubular atrophy without rejection. Management proceeded along the preeclampsia protocol with strict surveillance. Progression to reverse end-diastolic flow and recurrent fetal decelerations necessitated emergency caesarean delivery at 31&#xa0;weeks. Postpartum, patient achieved stable renal function and blood pressure, while preterm neonate required extended NICU care, however both were discharged in stable condition.</p> Conclusion <p>Pregnancy in renal transplant recipients requires meticulous multidisciplinary care. In cases where preeclampsia and graft dysfunction coexist, angiogenic biomarkers and selective renal biopsy can provide crucial diagnostic clarity. With individualized management, favourable maternal and neonatal outcomes are achievable even in complex scenarios.</p>

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Pregnancy After Renal Transplantation: Diagnostic Challenge of Distinguishing Severe Preeclampsia from Acute Graft Rejection—A Case Report and Review

  • 期刊论文

  • 发表日期：

    2026年2月21日

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  • Soniya Dhiman,
  • K. Aparna Sharma,
  • Soni Bharti,
  • Juhi Bharti,
  • Raj Kanwar Yadav,
  • Neena Malhotra

摘要

Background

Pregnancy after renal transplantation is increasingly encountered due to improved graft survival and safer immunosuppressive regimens. These pregnancies remain high-risk, with substantial maternal and fetal morbidity. Distinguishing severe preeclampsia from acute graft rejection poses a major diagnostic challenge, as both conditions share overlapping clinical features. This report highlights such a dilemma in the management of a renal transplant recipient with deteriorating renal parameters and hypertension in the late second trimester.

Case

A 29-year-old multigravida, a live donor renal transplant recipient with history of earlyonset severe preeclampsia and early neonatal loss conceived spontaneously. In current pregnancy, initial antenatal evaluation revealed stable graft function and normal aneuploidy screening. At 29 weeks, she developed severe hypertension, worsening proteinuria, rising creatinine, fetal growth restriction, and a culture-positive urinary tract infection. Despite intensified antihypertensive therapy, renal parameters continued to decline. The sFlt-1/PLGF ratio was borderline (84.5), leaving diagnostic uncertainty regarding preeclampsia versus acute graft rejection. An ultrasound-guided renal graft biopsy was performed, demonstrating interstitial fibrosis and tubular atrophy without rejection. Management proceeded along the preeclampsia protocol with strict surveillance. Progression to reverse end-diastolic flow and recurrent fetal decelerations necessitated emergency caesarean delivery at 31 weeks. Postpartum, patient achieved stable renal function and blood pressure, while preterm neonate required extended NICU care, however both were discharged in stable condition.

Conclusion

Pregnancy in renal transplant recipients requires meticulous multidisciplinary care. In cases where preeclampsia and graft dysfunction coexist, angiogenic biomarkers and selective renal biopsy can provide crucial diagnostic clarity. With individualized management, favourable maternal and neonatal outcomes are achievable even in complex scenarios.