Upload
ngodat
View
228
Download
0
Embed Size (px)
Citation preview
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