肾移植受者术后妊娠的回顾性队列研究

Aretrospective cohort study of pregnancy after kidney transplantation

目的:探讨肾移植后妊娠的安全性,总结肾移植后怀孕时机的选择以及孕期和围分娩期管理的相关经验。方法:本研究纳入2013年3月至2020年2月受孕的25例肾移植受者,以配对的同期非移植孕产妇75例为对照组,比较妊娠期情况、围产期结局以及对肾功能的影响。结果:移植组25例孕妇均顺利分娩健康婴儿。接受肾移植时受者年龄中位数为(25.6±3.2)岁,移植距妊娠的中位时间为(54.0±23.1)个月,均顺利生产单胎,92%(23/25)为剖宫产。怀孕期间,移植组子痫前期的发生率明显高于非移植组(20.0%比1.3%,P=0.001)。移植组孕妇妊娠中期血清肌酐较孕前有所降低,晚期较孕前增加,孕期肌酐变化趋势与非移植组一致,产后3~6个月恢复至孕前水平。40%(10/25)受者孕晚期存在尿蛋白,分娩半年内下降至阴性(5/10)或1+(4/10)。移植组所有受者孕期及产后半年内未发生排斥反应,移植肾功能稳定。他克莫司在怀孕后需增加剂量以维持浓度,产后恢复。结论:肾移植受者术后妊娠的合并症风险尽管高于普通人群,但总体风险可控。严格筛选备孕受者、调整免疫抑制药物、孕期和围分娩期的多科协作是安全妊娠分娩的重要保证。

Objective To evaluate the safety of pregnancy after kidney transplantation and summarize the optimal timing of pregnancy and the experience in the management during pregnancy and peripartum.Methods A total of 25 kidney transplant recipients were pregnant during March 2013 to February 2020.A matched cohort of 75 general pregnant women wasincluded as control.Results Twenty-five women successfully delivered healthy babies in the transplant group.The mean age at kidney transplantationwas(25.6±3.2)years old,and the mean interval between transplantation and conception was(54.0±23.1)months.92%(23/25)of recipients had cesarean surgery and all infants were singletons.During pregnancy,the incidence of preeclampsia was significantly higher in the transplant group(20.0%VS.1.3%,P=0.001)compared with matched control.Compared with pre-pregnancy,the serum creatinine levels of the recipients decreased in the second trimester(P<0.001)and increased in the third trimester(P=0.019),which was similar with the control group.In the third trimester,40%(10/25)of recipients in the transplant group had proteinuria,which decreased to negative(5/10)or 1+(4/10)within 6 months after delivery.No rejection occurred in all patients during pregnancy and 6 months after delivery.A higher dose of tacrolimus was needed to maintain the normal trough level after pregnancy,which returned to routine dose postpartum.Conclusions Although the risk of pregnancy was higher in kidney transplant recipients than that in non-transplant women,the overall risk was acceptable.Strict screening of patients preparing for pregnancy,adjustment of immunosuppressive drugs,and multi-disciplinary collaboration are important for safe pregnancy and delivery.