妊娠并发肾病综合征的临床研究

Clinical study of pregnancy complicated with nephrotic syndrome

目的探讨妊娠并发肾病综合征患者的妊娠结局及肾功能的变化。方法回顾性调查我院2003年至2007年间59例妊娠并发。肾病综合征患者的临床资料，包括患者出现肾病的时间、尿蛋白量、血浆向蛋白、Scr、血尿酸、血压；胎儿存活率、死亡率、早产率、出生体质量；以及孕妇产后随访蛋白尿、肾功能和血压情况。采用Logistic回归方法，分析影响妊娠患者的肾脏转归及胎儿预后的危险因素。结果孕妇出现蛋白尿孕周平均为（20．35±9．40）周，尿蛋白量（24h）3．5～15．0g，中位数5．1g；血浆白蛋白10～28g／L，中位数22．5g／L；Scr32～825μmol／L，中位数84μmol／L；血尿酸196～793μmol／L，中位数385．5μmol／L。妊娠高血压综合征发生率为75％，其中先兆子痫占55．5％。胎儿存活率72．9％（43／59），其中早产占76．7％（33／43）；低体质量儿占62．8％（27／43）。产后50％患者持续肾病综合征。24例原有慢性肾炎，其中75％患者蛋白尿较怀孕前有不同程度的增加。38例伴有肾功能受损，其中36.8％患者产后肾功能受损加重，23．7％进入终末期肾衰竭；其中80％发生在Scr≥265μmol／L的患者。89％患者产后持续高血压。Logistic回归结果提示，孕期高尿酸血症（P=0．018，OR=1．012）和Scr升高（P=0．039，OR=1．005）是孕妇产后肾功能受损加重的危险因素。高尿酸血症（P=0．012，OR=1．006）也是胎儿死亡的危险因素。结论妊娠并发肾病综合征患者的胎儿存活率低，其中高尿酸血症是威胁孕妇和胎儿的首要危险因素。

Objective To identify the outcome of pregnancy and the alteration of renal function in women with nephrotic syndrome. Methods From 2003 to 2007, 59 pregnant women with nephrotic syndrome in our hospital were enrolled in the study. Their clinical data were retrospectively analyzed, including the time of kidney disease onset, 24-hour proteinuria, serum albumin, serum creatinine, blood uric acid, blood pressure, fetal survival, fetal mortality, rate of premature delivery, birth weight of the newborn, and proteinuria, renal function, blood pressure of the patients during their postpartum follow-up. Logistic regression analysis was used to identify the risk factors influencing the outcome of the patients and the newborns. Results The average gestational week was （20.35±9.40） weeks when proteinuria was detected in these pregnant women. The 24-hour proteinuria ranged from 3.5 to 15 g/24 h （median 5.1 g/24 h）. The serum albumin was between 10 and 28 g/L （median 22.5 g/L）. The serum creatinine was between 32 and 825 μmol/L （median 84 μmol/L） and the serum uric acid ranged from 196 to 793 μmol/L （median 385.5 μmol/L）. Pregnancy-induced hypertension syndrome occurred in 75% of the patients, among whom 55.5% suffered from preeclampsia. Forty-three （72.9%） newborns survived , among whom 76.7% （33/43） were premature births and 62.8% （27/43） were low birth weight infants. 50% of the pregnant women still had nephrotic syndrome after delivery. 75% of 24 patients with pre-existing chronic glomerulouephritis had inereased proteinuria during pregnancy. Among the 38 patients with renal insufficiency, 36.8% had poorer renal function after delivery. 23.7% of the patients progressed into end stage renal failure after delivery, 80% of whom had serum creatinine ≥ 265 μmol/L. 89% of the patients had persistent hypertension after childbirth. The Logistic regression analysis indicated hyperurieemia during pregnancy （P=0.018, OR =1.012） and the increase of serum creatinine （P=0.039, OR=1.005） were risk factors of renal failure in pregnant women after delivery. Hyperuricemia （P=0.012, OR =1.006）was the risk factor of fetal death. Conclusions Pregnancy with nephrotic syndrome leads to a low fetal survival. Hyperuricemia is the most important risk factor of the poor outcome of pregnant women and newborn.