Azienda Ospedaliera Brotzu, Cagliari, Italy.
IRCCS San Raffaele Hospital, Milan, Italy.
J Nephrol. 2018 Oct;31(5):665-681. doi: 10.1007/s40620-018-0499-x. Epub 2018 Jun 14.
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".
肾移植（KT）通常被认为是恢复慢性肾脏病（CKD）女性生育能力的最佳方法。然而，KT 妊娠并非没有风险（特别是早产、胎儿小于胎龄和妊娠高血压疾病）。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≥60ml/min）、极少或无蛋白尿（通常定义为低于 500mg/dl）、正常或良好控制的血压（仅使用一种药物且无终末器官损伤迹象）、无近期急性排斥反应、良好的依从性和低剂量免疫抑制、不使用潜在致畸药物（霉酚酸和 m-Tor 抑制剂）以及移植后至少 1-2 年的间隔。在这种情况下，肾功能恶化的风险很小。对于“不理想”的情况，如 KT 后短期妊娠或高血压或肾功能衰竭背景下的妊娠，如何处理的了解较少。意大利肾脏病学会肾脏与妊娠小组的这份立场声明旨在回顾文献并讨论已知的 KT 后 CKD 的临床管理，特别关注在不理想条件下开始妊娠的女性。虽然这种情况下的经验有限，但在肾功能明显下降和蛋白尿的情况下，肾功能恶化的风险可能更高。单独控制良好的高血压似乎对结局的影响较小，即使它与低 GFR 和蛋白尿结合时可能会产生倍增效应。与其他肾脏病情况下一样，叠加性先兆子痫（PE）的定义不同，这会影响其真实发病率的计算。尚未显示非致畸免疫抑制剂之间有特定差异，但钙调磷酸酶抑制剂与胎儿生长受限和低出生体重有关。对于存在畸形或肾功能损害高风险的病例（使用霉酚酸或严重肾功能损害的妊娠），需要将临床和伦理方法结合起来，在这些方法中，除了母婴对，移植的肾脏是一个关键的“第三个元素”。
