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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">The possibility of a full term pregnancy is one of the benefits that women can obtain after solid organ transplantation&#46; Gonadal dysfunction is a consequence of renal failure or of other organ insufficiency and it can be recovered a few months after the graft begins to properly work&#46;<span class="elsevierStyleSup">1-3</span> The current information about pregnancy and solid organ transplantation was obtained from voluntary registers&#44; case reports and hospital retrospective surveys&#46; The voluntary registers were the ones that allowed the best information on this subject&#46;<span class="elsevierStyleSup">1-3 </span>The accumulated experience on renal transplantation<span class="elsevierStyleSup">1-6</span> is in contrast with the few reported or registered cases of simultaneous kidney and pancreatic transplantation &#40;SKPT&#41;&#46;<span class="elsevierStyleSup">1-3&#44; 6&#44; 7</span> There are common risks for both kinds of transplants in the fetus &#40;miscarriage&#44; preterm labor or malformations&#41;&#44; as well as in the mother &#40;high blood pressure&#44; preeclampsia and more frequent infections&#41; and the graft &#40;acute rejection and renal function worsening&#41;&#46;<span class="elsevierStyleSup">1-3</span> The effect of the pregnancy on graft function in case of SKPT and the problems associated to the presence of two organs within the pelvis are not clear&#46; In the present article we present a full term pregnancy in a patient&#44; who has undergone a SKPT&#44; and who maintained an adequate function of both grafts after the delivery&#44; and we update the relevant issues on this topic&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">We present a 35 years old female in her first pregnancy&#46; She had a history of type 1 diabetes mellitus&#44; renal failure&#44; and had undergone a SKPT in 2003&#46; Pancreatic graft was placed at the intraperitoneal cavity in the right iliac fossa&#44; and the renal graft was placed in the extraperitoneal left iliac fossa&#46; She received immunosuppression with Thymoglobulin&#44; tacrolimus&#44; mycophenolate mofetil &#40;MMF&#41; and steroids&#46; The steroids were withdrawn after 5 months&#46; Twenty-six months after the intervention the patient expressed her wish of getting pregnant&#46; At that time&#44; she was on tacrolimus&#44; MMF and statins&#44; her blood pressure was normal without pharmacological treatment&#44; she had no pathological proteinuria and both grafts had normal function&#46; The patient was informed about the risks of the pregnancy&#46; Treatment with statins and MMF was withdrawn and azathioprine was added&#46; The patient got pregnant and her pregnancy was followed up at the high-risk pregnancy outpatient clinic of the Obstetrics Department and the Nephrology Department&#46; The pregnancy went on without complications except for an episode of asymptomatic bacteriuria&#46; In the 28th week&#44; the patient was admitted to the hospital and the labor work began physiologically&#46; Two hours later&#44; sustained fetal bradycardia developed&#44; which did not revert&#46; The medical team on shift indicated an urgent cesarean section because of suspected loss of fetal well-being&#46; A male of 2&#44;980 grams was delivered&#44; who was evaluated as normal by the Neonatology team on call&#46; The postsurgical period was favorable for both the mother and the baby&#44; and given the excellent evolution&#44; they were discharged 4 days later&#46; On table I several interesting parameters of the patient before pregnancy&#44; at each trimester of the pregnancy&#44; and 5 months after the delivery are shown&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">More than 75&#37; of the hundreds of pregnancy cases in transplanted patients&#44; which are published or reported in different registers&#44; correspond to renal transplants&#44; followed by liver and heart transplant&#44; SKPT being less than 5&#37;&#46;<span class="elsevierStyleSup">1-3</span> That explains that the American and European guidelines<span class="elsevierStyleSup">8-10</span> refer mainly to renal transplant&#46; Although the pregnancy should be treated as high-risk&#44; if the criteria shown in table II are fulfilled it can be considered low-risk&#46;<span class="elsevierStyleSup">1&#44; 9&#44; 10</span></p><p class="elsevierStylePara">A higher risk of miscarriage&#44; preterm labor &#40;&#60; 37 weeks&#41; and low weight &#40;&#60; 2&#44;500 g&#41; has been reported in different transplant types&#46; The frequency of preterm labor and low weight was higher in the case of SKPT and in renal transplantation than in liver transplant&#46;<span class="elsevierStyleSup">1&#44; 2</span> On the other hand&#44; the frequency of high blood pressure&#44; preeclampsia and infections is higher among patients with SKPT&#44; while the incidence of acute rejection is similar to other transplants<span class="elsevierStyleSup">2</span> &#40;table III&#41;&#46; In the reported case&#44; the evolution was without complications except for the above-mentioned bacteriuria&#46; The pregnancy went on till full term and the fetus weight was normal&#46; That can be due to the normal renal function and the lack of hypertension and pathological proteinuria before and during the pregnancy&#46; In this sense&#44; a recent study shows that abnormal renal function &#40;plasma creatinine levels &#62; 1&#46;69 mg&#47;dL&#41; and the use of antihypertensive drugs before the pregnancy are independent risk factors for preterm delivery&#46; The reason in most cases is the performance of a cesarean section indicated because of high blood pressure&#44; preeclampsia and renal function worsening&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">The balance between the risk for acute rejection and the teratogenic effect of the drugs is another important issue to be taken into account&#46; It has been suggested that the pregnancy produces a state of immunosuppression&#46; But the current evidence points out that the uterus is an &#171;immune sanctuary&#187;&#44; while the mother maintains a competent immunological system&#46;<span class="elsevierStyleSup">1&#44; 9&#44; 10</span> So inadequate immunosuppression can lead to acute graft rejection&#46;<span class="elsevierStyleSup">1</span> Although a great deal of immunosuppressive drugs is currently available&#44; the adequate regime and doses are yet to be defined&#46;<span class="elsevierStyleSup">1&#44; 2&#44; 11</span> The FDA classifies the drugs into five categories according to the teratogenic risk &#40;in animal and&#47;or human studies&#41; that can be summarized as follows&#58; A&#61; remote possibility&#59; B &#61; no evident risk in humans&#59; C &#61; a risk in humans can not be ruled out &#40;evaluate risk&#47;benefit&#41;&#59; D &#61; evident risk in humans &#40;acceptable if the benefit is high&#41;&#59; X &#61; absolutely contraindicated&#46;<span class="elsevierStyleSup">1</span> Most immunosuppressive drugs are classically classified into the group C&#44; with the exception of azathioprine&#44; which belongs to group D&#46;<span class="elsevierStyleSup">1&#44; 2</span> However&#44; the FDA has recently changed the classification of MMF from category C to D &#40;October 2007&#41;&#46; In the reported case&#44; the patient was not on steroids and it was decided to maintain tacrolimus levels within the therapeutic range and to substitute MMF by azathioprine&#46; In that moment the modification was made following the European guidelines&#44; which contraindicated MMF and recommended azathioprine&#44;<span class="elsevierStyleSup">10</span> probably because the evidence with this drug was larger&#46; On the other hand&#44; a recent study shows that there is a higher incidence of structural anomalies in newborns of women with transplant&#44; who take MMF in comparison to other therapies&#46;<span class="elsevierStyleSup">12</span> Due to this fact and to the change of category made by the FDA&#44; it is better to retain us from the use of MMF in patients with transplant&#44; like other authors have also suggested&#46;<span class="elsevierStyleSup">1&#44; 9</span></p><p class="elsevierStylePara">In conclusion&#44; although the experience in pregnancy and simultaneous kidney and pancreas transplant is limited&#44; we believe that if the criteria known for the renal transplantation are fulfilled&#44; and if a immunosuppression similar to that on previous months can be maintained&#44; avoiding the drugs&#44; with which there is less experience&#44; then the risks for the mother&#44; the organs and the child&#44; though present&#44; can be acceptable&#46; </p>"
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          "identificador" => "xpalclavsec438514"
          "palabras" => array:1 [
            0 => "Simultaneous kidney-pancreas transplantation"
          ]
        ]
        3 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec438516"
          "palabras" => array:1 [
            0 => "Diabetes mellitus"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "es" => array:1 [
        "resumen" => "Los efectos del embarazo en receptoras de un trasplante renal han sido ampliamente descritos aunque su impacto sobre el injerto&#44; el receptor o en el feto es a&#250;n motivo de debate&#46; La experiencia en el trasplante simult&#225;neo de ri&#241;&#243;n y p&#225;ncreas es escasa debido al limitado n&#250;mero de casos publicados lo que incrementa la incertidumbre sobre la pauta a seguir en esta situaci&#243;n&#46; Se describe un caso de embarazo a t&#233;rmino en una receptora de trasplante simult&#225;neo de ri&#241;&#243;n y p&#225;ncreas de 35 a&#241;os de edad a los 34 meses del implante&#46; Tras modificaciones en el tratamiento inmunosupresor&#44; el embarazo evoluciona favorablemente dando a luz la paciente&#44; mediante ces&#225;rea de urgencia por sufrimiento fetal&#44; a las semanas 38 de gestaci&#243;n&#46; A los 5 meses del parto ambos injertos funcionan normalmente siendo el desarrollo del ni&#241;o totalmente normal&#46;"
      ]
      "en" => array:1 [
        "resumen" => "The effects of pregnancy on kidney transplant recipients have been widely described&#44; although its impact on the mother&#44; the fetus and the graft is still debated&#46; Experience in simultaneous kidney-pancreas transplantation is limited&#44; with few reported cases&#44; which increases uncertainty about guidelines to follow in this situation&#46; We describe a case of successful pregnancy in a 35 year-old patient who underwent simultaneous pancreas-kidney transplantation 34 months before delivery&#46; After modifications in immunosuppressive therapy &#40;with tacrolimus and mycophenolate&#44; the latter being switched to azathioprine&#41;&#44; pregnancy evolved favourably&#46; Delivery was by caesarean section due to fetal distress at 38 weeks of gestational age&#46; Five months after delivery the child shows normal development while both pancreas and kidney grafts show normal function&#46;"
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliography"
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          "bibliografiaReferencia" => array:13 [
            0 => array:3 [
              "identificador" => "bib1"
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                0 => array:3 [
                  "referenciaCompleta" => "McKay DB, Josephson MA. Pregnancy in recipients of solid organs. Effects on mother and child. N Engl J Med 2006; 354: 1281-93."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
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                0 => array:3 [
                  "referenciaCompleta" => "Armenti VT, Radomski JS, MOritz MJ y cols. Report from the National Transplantation Pregnancy Registry (NTPR): outcome of pregnancy after transplantation. En: Cecka JM, Terasaki PI, eds. Clinical Transplant 2004. Los Angeles: UCLA Inmunogenetics Center, 2004: 103-19."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Sibanda N, Briggs JD, Davison JM, Johnson RJ, Rudge C. Pregnancy after organ transplantation: a report from the UK Transplant Pregnancy Registry. Transplantation 2007; 83: 1301-1307."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Yassaee F, Moshiri F. Pregnancy outcome in kidney transplantation patients. Urol J 2007; 4: 14-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17514605" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
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                    0 => null
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                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Oliveira LG, Sass N, Sato JL, Ozaki KS, Medina Pestana JO. Pregnancy alter renal transpaltation. A five years single center experience. Clin Transplant 2007; 21: 301-4. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17488376" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Jain AB, Shapiro R, Scantlebury VP, Potdar S, Jordan ML, Florh J, Marcos A, Fung JJ. Pregnancy after kidney and kidney-pancreas transplantation under tacrolimus: a single center´s experience. Tranplantation 2004; 77: 897-902."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Zivny´ J, Adamec M, Parízek T, Hájek Z, Cindr J, Saudek J, Vítko S. Pregnancy and labor after combined pancreas-kidney transplantation in Czech Republic. Ceska Gynekol 2005; 70: 362-6. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16180796" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Hou S. Pregnancy in chronic renal insuffiency and end stage renal disease. Am J Kidney Dis 1999; 33: 235-52. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10023634" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "McKay DB, Josephson MA, Armenti VT y cols. Reproduction and transplantation: report on the AST Consensus Conference on Reproductive Issues and Transplantation. Am J Transplant 2005; 5: 1592-9."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "EBPG Expert Group in Renal transplantation. European best practice guide-lines for renal transplantation. Section IV.10. Long-term management of the transplant recipients. Nephrol Dial Transplant 2002; 17: Supl. 4: 50-5."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Armenti VT, Moritz MJ, Cardonock EH, Davison JM. Immunosuppression in pregnancy: choices for infant and maternal health. Drugs 2002; 62: 2361-75. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12396228" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
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              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "www.fda.gov/medwatch/SAFETY/2007/safety07.htm"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
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              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Sifontis NM, Coscia LA, Constantinescu S, Lavelanet AF, Morits MJ, Armenti VT. Pregnancy in solid organ transplant recipients with exposure to mycophenolate mofetil or sirolimus. Transplantation 2006; 82: 1698-1702.  <a href="http://www.ncbi.nlm.nih.gov/pubmed/17198262" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
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              ]
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