Diapositiva 1

GRAVIDANZA DOPO TRAPIANTO
RENALE. INDAGINE
CONOSCITIVA DEL GdS : DATI
PRELIMINARI
TAORMINA,15-16 Aprile 2011
Pierluigi Di Loreto MD PhD
Nephrology Dialysis Transplantation Unit
San Bortolo Hospital Vicenza Italy
Gruppo di Studio
TRAPIANTO DI RENE E RENE PANCREAS
Indagine conoscitiva sulla
gestione della gravidanza
nelle donne portatrici di
trapianto renale.
Valutazione della
gravidanza nelle donne
portatrici di trapianto
renale.
ANAMNESI MATERNA PRIMA DEL
TRAPIANTO DI RENE
COD PZ TIPO DI
NEFROPATIA
prima 3 lettere nome +
prime 3 lettere
cognome+(gg+mm+anno)
di nascita
Esempio: Iliara Balbo nata il
01/01/1974
Cod paz ILABAL010174
ETA’ AD
INZIO
DIALISI
METODICA
DIALITICA
1: Glomerulonefriti
2: Nefropatia diabetica
3: Nefroangiosclerosi
4: Rene policistico
5: Nefropatia tubulointerstiziale
6: Nefropatia ostruttiva
7: IgA nefropatia
8: Altro
IPERTEN DIABETE
. ART.
MELLITO
0: assente
1: presente
1: HD
2: PD
ANAMNESI MATERNA LEGATA AL
TRAPIANTO DI RENE PRIMA DELLA
GRAVIDANZA
DONATORE
CREAT
PRIMA
GRAV
1:cadavere
2: vivente
STEROIDE
(mg/dl)
AZA
INIBITORI
CALCINEURINE
MMF
0: assente
1: presente
SIROLI
MUS
EVEROL
IMUS
ANAMNESI MATERNA REALTIVA ALLA
GRAVIDANZA
ETA’
MATERNA
MESI
FRA TX E
GRAV
STEROIDE
0: assente
1: presente
CSA AZA
TACRO
LIMUS
PROFILASSI
CON
ASPIRINETTA
OUTCOME MATERNO
CREAT
ATTORNO A
20 WG
COMPLICANZE
MATERNE
PARTO
CREAT AL 6
MESE DOPO
IL PARTO
1: preeclampsia
2: ipertensione arteriosa
3: IRA (aumento creat >25%)
4: proteinuria
5: distacco di placenta
6: perdita del graft
7: IVU
8: aborto spontaneo
7: altro
CREAT AD 1
AA DOPO IL
PARTO
1: via vaginale
2: taglio cesario
ULTIMA
CREAT
DISPONIBI
LE
ULTIMA
PROTEINU
RIA
DISPONIBI
LE
OUTCOME FETALE
OUTCOME
FETALE
ETA’
PESO
GESTAZIO ALLA
NALE
NASCITA
1: nato a termine
2: nato pretermine
3: SGA
gr
settimane
COMPLIC
ANZE
FETALI
APGAR AL
6’
1 IUGR
2 ARDS
3 S di
Klinefelter
4 nascita
pretermine
5 altro
APGAR
AL9’
CRITERIA FOR CONSIDERING PREGNANCY
IN RENAL TRANSPLANT RECIPIENTS
• Good general health for about 2 years after transplantation
• Good stable allograft function (Serum Cr < 2 mg/die), preferably
•
•
•
•
•
<1,5 mg/die
No recent episodes of acute rejection and no evidence of ongoing
rejection
Normal BP or minimal anti-hypertensive regimen (only one drug)
Absence or minimal proteinuria (<0,5 gr/die)
Normal allograft ultrasound (absence of pelvicaliceal distension)
Recommended immunosuppression:
Prednisone <15 mg/die
Azathioprine < 2 mg/Kg/die
Cyclosporine or Tacrolimus at therapeutic levels
MMF and Sirolimus are controindicated and they should be stopped
6 weeks before conception is attempted
MATERIALS AND METHODS
• Retrospective study including all pregnant
women transplanted
• Variables analyzed:
– Type of nephropathy
– Patient age when dialysis began, at tx, at pre.cy
– Time between dialysis and tx, between tx and
childbirth
– Immunosuppressive theraphy
– Mother and fetal complications
– Type of delivery
– Baby weight and Apgar score
– Baby and mother follow up
R E S U L T S
N° of Patients
31
Type of nephropathy
6
1
4
3
9
1
2
5
Chronic Pielonephritis
Post Partum Cortical Necrosis
IgA Nephropathy
Diabetic Nephropathy
Unknown Nephropathy
ADPKD
Nephroang.sis
GN
RESULTS II
PT Age at Start of HD (Y)
PT Age at TX (Y)
PT Age at Pregnancy (Y)
Time between HD-TX (M)
Time between Tx-Childbirth
Cadaver Donor
Living donor
N° OF Pregnancies
HBP before Pre.cy
Immunos.ve Theraphy
28,05 (SD 2,35)
30,25 (SD 2,52)
33,9 (SD 3,1)
16
(SD 22,3)
4,45 (SD 3,15)
29
02
32
19
18 Pred.ne, CyA, AZA
06 FK, Prednisone
07 Prednisone, CyA
MATERNAL RENAL FUNCTION
• BEFORE PREGNANCY: Creat= 1.1 ± 0.115 mg/dl
• DURING PREGNANCY: Creat= 0.9 ± 0.1 mg/dl
• AFTER PREGNANCY: Creat= 1.09 ± 0.125 mg/dl
MOTHER COMPLICATIONS
DURING PREGNANCY
AR
2
OTHER SA
2
2
NNP
4
HBP
1
UTI
5
IPD
1
PE
4
OBSTETRIC DATA
• MODE OF DELIVERY
• CAESAREAN 99%
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
APGAR INDEX
CHILDBIRTHS
TERMBIRTH
PRETERM BIRTH
SGA
GESTATIONAL AGE (W)
BABY WEIGHT (G)
INTENSIVE CARE
BREASTFEEDING
VAGINAL
1%
Between 4/8 and 6/9
30
8
22
2
35,4 (SD 3,15)
2350 (SD 890)
5 BABIES
0
FOETAL COMPLICATIONS
ADRS
1
KLINEFELTER SYNDROME
1
IUGR
2
MOTHER FOLLOW UP
•
•
•
•
•
•
•
ACUTE REJECTION
GRAFT LOSS WITHIN 2 Y
KIDNEY FUNCTION (sCr)
PROTEINURIA ABSENT
PROTEINURIA >0,3 gr/die
RAS BLOCKERS
ARB + CALCIUM ANT.STS
•
•
•
•
•
•
•
0
0
1,09 mg/dl (SD 0,125)
22 PTS
09 PTS
13 PTS
09 PTS
BABY FOLLOW UP
• ANY SIGNIFICANT DISEASE
DATA FROM
NTPR, EDTA, U.K.TR.PRE.RE., ISN
Live birth
Miscarriage
Therapeutic Termination(<24w)
Intrautherin fetal death(<24 w)
Ectopic Pregnancy
Stillbirth
Labor Spontaneus
Labor induced
Elective caesarean
Vaginal delivery
Caesarean delivery
Gestational age
Pre-term delivery (<37wk)
Birth weight
Low birth weight (<2500 gr)
70%
14%
11%
02%
01%
02%
12%
24%
64%
21%
79%
36,60,6 wk
50%
251680 gr
55%
MOTHER-FETAL COMPLICATIONS
MO T H E R
• INFECTIONS
• TRANSIENT REDUCTION OF
•
•
•
•
•
•
•
•
•
RENAL FUNCTION
PE
PROTEINURIA
HIGH BLOOD PRESSURE
GRAFT LOSS WITHIN 2 YEARS
FROM DELIVERY
INTERNAL PLACENTA
DETACHMENT
UREMIC EMOLITIC SINDROME
DIABETES
ACUTE REJECTION
NON IMMUNOLOGICAL
KIDNEY DISFUNCTION
FETAL
•
•
•
•
•
•
•
•
RESPIRATORY DISTRESS
INFECTIONS
SURRENAL INSUFFICIENCY
LYMPHOCITE CHROSOME
DEFECTS
LEUCOPENIA-ANEMIA
THROMBOCYTOPENIA
HYDRONEPHROSIS
MALFORMATIONS
MOTHER COMPLICATIONS
AR
9%
INFECTIONS
25%
PE
30%
HIGH BLOOD
PRESSURE
70%
NON IMM. KIDNEY DIS.TION
12%
PE (%) IN RTR AND NON RTR
35
30
25
20
15
10
5
0
RTR
NON RTR
GRAFT LOSS (%) WITHIN TWO
YEARS FROM DELIVERY IN RTR
18
16
14
12
10
8
6
4
2
0
SCr>2.5 mg/dl
SCr<2.5 mg/dl
MORTALITY
• MOTHER
Not affected from tx
• PERINATAL
10%
MOTHER - BABY FOLLOW UP
• LONG TERM RENAL
FUNCTION NOT
AFFECTED FROM
PREGNANCY
(Mother)
• NORMAL GROWTH
95%
• REQUIRED
EDUCATIONAL
SUPPORT 16%
11% GENERAL
POPULATION
CONCLUSIONS
• OUR DATA ARE IN AGREEMENT WITH
THOSE OF THE LITERATURE
• PREGNANCY AFTER KIDNEY
TRANSPLANT, ALTHOUGH POSSIBLE,
CARRIES AN ELEVATED RISK AND
THEREFORE PATIENTS HAVE TO BE
REFERRED TO HIGHLY SPECIALIZED
CENTERS
• PREGNANCY IS NOT WITHOUT RISKS
AS IN A DIFFICULT JUMP; WHAT IS
IMPORTANT EXACTLY AS BEFORE A