A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology.
A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology.
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DOI：
10.1007/s40620-018-0499-x
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发表时间：
2018-10
影响因子：
3.4
通讯作者：
Kidney and Pregnancy Study Group of the Italian Society of Nephrology
中科院分区：
文献类型：
--
作者：
Cabiddu G;Spotti D;Gernone G;Santoro D;Moroni G;Gregorini G;Giacchino F;Attini R;Limardo M;Gammaro L;Todros T;Piccoli GB;Kidney and Pregnancy Study Group of the Italian Society of Nephrology
肾移植（KT）通常被认为是最能恢复慢性肾病（CKD）女性生育能力的方法。然而，KT妊娠并非没有风险（特别是早产、小于胎龄儿和妊娠期高血压疾病）。潜在KT母亲的理想特征包括“正常”或“良好”的肾功能（通常定义为肾小球滤过率，GFR ≥ 60 ml/min），少量或无蛋白尿（通常定义为低于500 mg/dl），正常或控制良好的血压（仅一种药物，无终末器官损伤迹象），近期无急性排斥反应，依从性良好，低剂量免疫抑制，不使用潜在的致畸药物（霉酚酸和m-Tor抑制剂），移植后间隔至少1-2年。在这种情况下，几乎没有肾功能恶化的风险。对于如何处理“非理想”情况，如KT后短时间内怀孕，或在高血压或肾功能衰竭的情况下怀孕，人们知之甚少。意大利肾脏病学会肾脏和妊娠组的这一立场声明的目的是回顾文献，并讨论KT后CKD的临床管理，特别关注在非理想条件下开始妊娠的女性。虽然此类病例的经验有限，但在肾功能显著降低和存在蛋白尿的病例中，肾功能恶化的风险可能更高。控制良好的高血压本身似乎与预后不太相关，即使它的影响可能是倍增的，如果结合低GFR和蛋白尿。与其他肾脏疾病一样，叠加先兆子痫（PE）的定义不同，这影响了其真实的发病率的计算。非致畸性免疫抑制药物之间无特异性差异，但钙调磷酸酶抑制剂与胎儿生长受限和低出生体重相关。在畸形或肾功能损害的高风险病例（使用麦考酚酸或严重肾功能损害的妊娠）中，临床选择需要将临床和伦理方法结合起来，其中，除了母亲和孩子之外，移植肾是至关重要的“第三要素”。
Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes “normal” or “good” kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1–2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage “non-ideal” situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial “third element”.
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