GRAVIDANZA DOPO TRAPIANTO RENALE. INDAGINE

CONOSCITIVA DEL GdS : DATI PRELIMINARI

Pierluigi Di Loreto MD PhDNephrology Dialysis Transplantation Unit

San Bortolo Hospital Vicenza Italy

TAORMINA,15-16 Aprile 2011

Gruppo di StudioTRAPIANTO 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

ETA’ AD INZIO DIALISI

METODICADIALITICA

IPERTEN. ART.

DIABETE MELLITO

prima 3 lettere nome +

prime 3 lettere

cognome+(gg+mm+anno)

di nascita

Esempio: Iliara Balbo nata il

01/01/1974

Cod paz ILABAL010174

1: Glomerulonefriti

2: Nefropatia diabetica

3: Nefroangiosclerosi

4: Rene policistico

5: Nefropatia tubulo-

interstiziale

6: Nefropatia ostruttiva

7: IgA nefropatia

8: Altro

1: HD

2: PD

0: assente

1: presente

ANAMNESI MATERNA LEGATA AL TRAPIANTO DI RENE PRIMA DELLA

GRAVIDANZA

1:cadavere

2: vivente (mg/dl)

0: assente

1: presente

DONATORE CREAT PRIMA GRAV

STEROIDE AZA INIBITORI CALCINEURINE

MMF SIROLIMUS

EVEROLIMUS

ANAMNESI MATERNA REALTIVA ALLA GRAVIDANZA

0: assente

1: presente

ETA’ MATERNA

MESI FRA TX E GRAV

STEROIDE CSA AZA TACROLIMUS

PROFILASSICON ASPIRINETTA

1: via vaginale

2: taglio cesario

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

OUTCOME MATERNO

CREATATTORNO A 20 WG

COMPLICANZE MATERNE

PARTO CREAT AL 6 MESE DOPO IL PARTO

CREAT AD 1 AA DOPO IL PARTO

ULTIMA CREAT DISPONIBILE

ULTIMA PROTEINURIADISPONIBILE

OUTCOME FETALE

1: nato a termine

2: nato pretermine

3: SGA

settimane

gr1 IUGR

2 ARDS

3 S di

Klinefelter

4 nascita

pretermine

5 altro

OUTCOME FETALE

ETA’ GESTAZIONALE

PESO ALLA NASCITA

COMPLICANZE FETALI

APGAR AL 6’

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 ongoingrejection

• 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 levelsMMF and Sirolimus are controindicated and they should be stopped6 weeks before conception is attempted

MATERIALS AND METHODS

• Retrospective study including all pregnantwomen 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

Type of nephropathy

31

6 Chronic Pielonephritis1 Post Partum Cortical Necrosis4 IgA Nephropathy3 Diabetic Nephropathy9 Unknown Nephropathy1 ADPKD2 Nephroang.sis5 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

SA2

NNP4

PE4

IPD1

UTI5

HBP1

AR2

OTHER2

OBSTETRIC DATA

• MODE OF DELIVERY

• APGAR INDEX

• CHILDBIRTHS

• TERMBIRTH

• PRETERM BIRTH

• SGA

• GESTATIONAL AGE (W)

• BABY WEIGHT (G)

• INTENSIVE CARE

• BREASTFEEDING

• CAESAREAN 99% 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

IUGR2

ADRS1

KLINEFELTER SYNDROME1

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 FROMNTPR, EDTA, U.K.TR.PRE.RE., ISN

Live birthMiscarriageTherapeutic Termination(<24w)Intrautherin fetal death(<24 w)Ectopic PregnancyStillbirthLabor SpontaneusLabor inducedElective caesareanVaginal deliveryCaesarean deliveryGestational agePre-term delivery (<37wk)Birth weightLow birth weight (<2500 gr)

70%14%11%02%01%02%12%24%64%21%79%36,60,6 wk

50%

251680 gr55%

MOTHER-FETAL COMPLICATIONS

• 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

• RESPIRATORY DISTRESS

• INFECTIONS

• SURRENAL INSUFFICIENCY

• LYMPHOCITE CHROSOME DEFECTS

• LEUCOPENIA-ANEMIA

• THROMBOCYTOPENIA

• HYDRONEPHROSIS

• MALFORMATIONS

MO T H E R F E T A L

MOTHER COMPLICATIONS

HIGH BLOODPRESSURE

70%

INFECTIONS25%

PE30%

NON IMM. KIDNEY DIS.TION12%

AR9%

PE (%) IN RTR AND NON RTR

0

5

10

15

20

25

30

35

RTR NON RTR

GRAFT LOSS (%) WITHIN TWO YEARS FROM DELIVERY IN RTR

0

2

4

6

8

10

12

14

16

18

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 JUMP IS TO LOOK BEFORE YOU LEAP