**Recommendations**


if the dose of prednisone has been decreased to 15 mg (Penn I, 1980). Prednisolone traverses the placenta but 90 % of maternal dose is metabolized within the placenta and not reaching to fetus (Blanford 1977). In addition if pregnancy is occurring after 2 years of transplant, recipient already on very small dose of Prednisolone. Steroids can also aggravate hypertension in moth‐ er; mothers are more prone to infections if steroid dose is still high at time of conception. Premature rupture of membrane is another complication reported in relation of steroids. Therefore, it is recommended to get conceive when steroid dose is reduced to minimal. Reports from azathiaprine era through cyclosporine era have not identified specific malformations among infants born to transplant recipients (Armenti 2000). Radioactive labeling studies in humans have shown that 64–93% of Azathioprine administered to mothers appears in fetal blood as inactive metabolites (Sarikoski S, 1973). Cyclosporine metabolism appears to be in‐ creased during pregnancy and higher doses may be required to maintain plasma levels in the therapeutic range (Muirhead N, 1992). Data concerning the effect of tacrolimus on pregnancy is scarce. A report of 100 pregnant women (which included all organ transplant recipients), among 84 treated with tacrolimus, 68 progressed to a live birth, with 60% of deliveries being premature (Kainz A, 2000). Teratogenecity of mycophenolate mofetil is not yet confirmed, therefore it is recommended to switch over to azathiaprine in female who are planning to conceive. A study has reported low number of T and B cells at birth in infants born to mothers who were on immunosuppressants, but these were normalized after few months. (Di Paolo 2000) Most published studies related to subject have not described clear cut congenital mal‐ formations or autoimmune disorders to children born to transplant recipients, though sporadic

case reports which could be related to exposure risk of disease in general population.

Sparse data is available on recommendations for breast feeding from immunosuppressant mothers. Study published on cyclosporine levels in breast milk reveals cyA levels in milk equivalent to mother's serum. (Moretti 2003) This leads to conclusion that females who are on cyclosporine should not fed their babies, whereas the fact that small amounts of azathiaprine and Prednisolone are excreted in milk (Coulam 1982) can provide an opportunity to consider feeding those babies whose mothers are on these two agents only. French et al. reported the first case of measurement of tacrolimus levels in human milk; suggest that maternal therapy with tacrolimus may be compatible with breast-feeding. (French 2003). Level of Tacrolimus was calculated in breast milk in this case but this was single case report. Data on other drugs

**9. Breast feeding by transplant recipients**

282 Current Issues and Future Direction in Kidney Transplantation

is still lacking.

**Recommendations**

**1.** preconception counseling is a must

**2.** good general health for about 2 years after transplant

