Kidney transplantation during a twin pregnancy. Case report and review of the literature.

Kidney transplant in a pregnant woman is exceptional, with only six cases being reported. Pregnancy was not known at the time of the transplant in five of these cases. We report the case of a 26-year-old woman who was diagnosed as carrying a twin pregnancy 4 months after starting hemodialysis. In order to improve the survival chances for the twins, she underwent an orthotopic renal transplant from a living donor at 20 weeks of gestation. The allograft functioned immediately and 4 weeks passed without incident. At the 26th week of gestation, the patient had a precipitous labor, delivering two male babies with no malformations, weighing 755 and 890 g, who died due to respiratory failure. The allograft worked normally afterwards. Sixteen months later, the patient delivered a normal 37 weeks' gestation baby. The renal graft continued working normally for the next 20 years, after which signs of chronic allograft nephropathy developed. Azathioprine was replaced with mycophenolate mofetil. At the last evaluation, 23 years after transplant, the patient's serum creatinine was 2.9 mg/dl and her estimated glomerular filtration rate (eGFR) was 22 ml/min/1.73 m. This unique case demonstrates that it is possible to perform an orthotopic kidney transplant in a 20-week twin-gestation, with a long graft survival time.