移植肾后急性排斥反应与子痫前期的鉴别诊断。

Differentiating Acute Rejection From Preeclampsia After Kidney Transplantation.

机构信息

Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, California; Transplant Pregnancy Registry International, Gift of Life Institute, and the Section of Nephrology, Department of Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania; the Department of Surgery, Lehigh Valley Health Network, Allentown, Pennsylvania; and the Department of Surgery, Morsani College of Medicine, Tampa, Florida.

出版信息

Obstet Gynecol. 2021 Jun 1;137(6):1023-1031. doi: 10.1097/AOG.0000000000004389.

DOI:10.1097/AOG.0000000000004389

PMID:33957644

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC8141043/

Abstract

OBJECTIVE

To evaluate the clinical and laboratory characteristics in pregnancy that differentiate preeclampsia from acute renal allograft rejection and to investigate the maternal, neonatal, and graft sequelae of these diagnoses.

METHODS

We conducted a retrospective case-controlled registry study of data abstracted from Transplant Pregnancy Registry International deliveries between 1968 and 2019. All adult kidney transplant recipients with singleton pregnancies of at least 20 weeks of gestation were included. Acute rejection was biopsy proven and preeclampsia was diagnosed based on contemporary criteria. Variables were compared using χ2, Fisher exact, and Wilcoxon rank sum tests as appropriate. Multivariable linear regression was used to analyze preterm birth. Kaplan-Meier curves with log-rank test and Cox proportional hazards model were used to compare graft loss over time.

RESULTS

There were 26 pregnant women with biopsy-confirmed acute rejection who were matched by the year they conceived to 78 pregnant women with preeclampsia. Recipients with acute rejection had elevated peripartum serum creatinine levels (73% vs 14%, P<.001), with median intrapartum creatinine of 3.90 compared with 1.15 mg/dL (P<.001). Conversely, only patients with preeclampsia had a significant increase in proteinuria from baseline. Although there were no significant differences in maternal outcomes, graft loss within 2 years postpartum (42% vs 10%) and long-term graft loss (73% vs 35%) were significantly increased in recipients who experienced acute rejection (P<.001 for both). The frequency of delivery before 32 weeks of gestation was 53% with acute rejection and 20% with preeclampsia. After controlling for hypertension and immunosuppressant use, acute rejection was associated with higher frequency of delivery at less than 32 weeks of gestation (adjusted odds ratio 4.04, 95% CI 1.10-15.2).

CONCLUSION

In pregnancy, acute rejection is associated with higher creatinine levels, and preeclampsia is associated with increased proteinuria. Acute rejection in pregnancy carries a risk of prematurity and graft loss beyond that of preeclampsia for kidney transplant recipients.

FUNDING SOURCE

The Transplant Pregnancy Registry International is supported in part by an educational grant from Veloxis Pharmaceuticals.

摘要

目的

评估区分子痫前期与急性肾移植排斥反应的妊娠临床和实验室特征，并探讨这些诊断的母婴、新生儿和移植物后遗症。

方法

我们对 1968 年至 2019 年期间国际移植妊娠注册中心分娩的资料进行了回顾性病例对照登记研究。所有接受过单胎妊娠至少 20 周的成人肾移植受者均被纳入。急性排斥反应经活检证实，子痫前期的诊断基于当代标准。采用卡方检验、Fisher 确切检验和 Wilcoxon 秩和检验比较变量。采用多元线性回归分析早产。采用 Kaplan-Meier 曲线和对数秩检验及 Cox 比例风险模型比较随时间的移植物丢失。

结果

共有 26 例经活检证实的急性排斥反应孕妇与按妊娠年份匹配的 78 例子痫前期孕妇相匹配。急性排斥反应患者的围产期血清肌酐水平升高（73%比 14%，P<.001），中位产时肌酐水平为 3.90 比 1.15 mg/dL（P<.001）。相反，只有子痫前期患者的蛋白尿有明显的基线升高。尽管母婴结局无显著差异，但急性排斥反应患者在产后 2 年内移植物丢失（42%比 10%）和长期移植物丢失（73%比 35%）显著增加（均 P<.001）。急性排斥反应组的早产发生率为 53%，子痫前期组为 20%。控制高血压和免疫抑制剂的使用后，急性排斥反应与小于 32 周分娩的频率更高相关（调整后的比值比 4.04，95%置信区间 1.10-15.2）。