For patients and caregivers to be fully informed about how living organ donation or prior kidney injury affects future health, we need to better understand the role of kidney reserve in physiological adaptation, especially during pregnancy. Importantly, epidemiological studies reason that live kidney donors are at increased risk for developing preeclampsia, a hypertensive disorder of pregnancy with serious implications for maternal and fetal health. Despite the import of this finding, the mechanistic basis for this increased risk is not understood. In this issue of the JCI, Dupont, Berg, and co-authors provide strong evidence that impaired placental perfusion, placental ischemia, increased soluble fms-like tyrosine kinase 1 (sFLT1), and a maternal preeclampsia–like phenotype are associated with an inability to upregulate the l-tryptophan–derived l-kynurenine pathway during pregnancy in mice with blunted renal reserve. These surprising revelations underscore the curious quiddity of l-tryptophan.
Philip A. Marsden