Gosselink Margriet E, van Buren Marleen C, Kooiman Judith, Groen Henk, Ganzevoort Wessel, van Hamersvelt Henk W, van der Heijden Olivier W H, van de Wetering Jacqueline, Lely A Titia
Department of Obstetrics and Gynaecology, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, the Netherlands.
Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands.
Kidney Int. 2022 Oct;102(4):866-875. doi: 10.1016/j.kint.2022.06.006. Epub 2022 Jun 28.
Although numbers of pregnancy after kidney transplantation (KT) are rising, high risks of adverse pregnancy outcomes (APO) remain. Though important for pre-conception counselling and pregnancy monitoring, analyses of pregnancy outcomes after KT per pre-pregnancy estimated glomerular filtration rate-chronic kidney disease (eGFR-CKD)-categories have not been performed on a large scale before. To do this, we conducted a Dutch nationwide cohort study of consecutive singleton pregnancies over 20 weeks of gestation after KT. Outcomes were analyzed per pre-pregnancy eGFR-CKD category and a composite APO (cAPO) was established including birth weight under 2500 gram, preterm birth under 37 weeks, third trimester severe hypertension (systolic blood pressure over 160 and/or diastolic blood pressure over 110 mm Hg) and/or over 15% increase in serum creatinine during pregnancy. Risk factors for cAPO were analyzed in a multilevel model after multiple imputation of missing predictor values. In total, 288 pregnancies in 192 women were included. Total live birth was 93%, mean gestational age 35.6 weeks and mean birth weight 2383 gram. Independent risk factors for cAPO were pre-pregnancy eGFR, midterm percentage serum creatinine dip and midterm mean arterial pressure dip; odds ratio 0.98 (95% confidence interval 0.96-0.99), 0.95 (0.93-0.98) and 0.94 (0.90-0.98), respectively. The cAPO was a risk indicator for graft loss (hazard ratio 2.55, 1.09-5.96) but no significant risk factor on its own when considering pre-pregnancy eGFR (2.18, 0.92-5.13). This was the largest and most comprehensive study of pregnancy outcomes after KT, including pregnancies in women with poor kidney function, to facilitate individualized pre-pregnancy counselling based on pre-pregnancy graft function. Overall obstetric outcomes are good. The risk of adverse outcomes is mainly dependent on pre-pregnancy graft function and hemodynamic adaptation to pregnancy.
尽管肾移植（KT）后妊娠的数量在增加，但不良妊娠结局（APO）的高风险仍然存在。虽然对于孕前咨询和孕期监测很重要，但此前尚未大规模开展过按孕前估计肾小球滤过率-慢性肾脏病（eGFR-CKD）类别对KT后妊娠结局的分析。为此，我们在荷兰开展了一项全国性队列研究，纳入KT后妊娠超过20周的连续单胎妊娠。按孕前eGFR-CKD类别分析结局，并建立了一个综合APO（cAPO），包括出生体重低于2500克、孕37周前早产、孕晚期严重高血压（收缩压超过160和/或舒张压超过110 mmHg）和/或孕期血清肌酐升高超过15%。在对缺失预测值进行多次插补后，采用多水平模型分析cAPO的危险因素。总共纳入了192名女性的288次妊娠。总活产率为93%，平均孕周35.6周，平均出生体重2383克。cAPO的独立危险因素为孕前eGFR、孕中期血清肌酐下降百分比和孕中期平均动脉压下降；比值比分别为0.98（95%置信区间0.96 - 0.99）、0.95（0.93 - 0.98）和0.94（0.90 - 0.98）。cAPO是移植肾丢失的风险指标（风险比2.55，1.09 - 5.96），但在考虑孕前eGFR时，其本身不是显著的危险因素（2.18，0.92 - 5.13）。这是关于KT后妊娠结局最大且最全面的研究，包括肾功能不佳女性的妊娠情况，以便根据孕前移植肾功能进行个体化的孕前咨询。总体产科结局良好。不良结局的风险主要取决于孕前移植肾功能和对妊娠的血流动力学适应情况。
