抗中性粒细胞胞质抗体相关性肾炎患者的妊娠结局  

Pregnancy outcomes in patients with antineutrophil cytoplasmic antibody-associated glomerulonephritis

作　　者：冯小翩 陈樱花 刘正钊 章海涛 胡伟新 FENG Xiaopian;CHEN Yinghua;LIU Zhengzhao;ZHANG Haitao;HU Weixin(National Clinical Research Center of Kidney Diseases,Jinling Hospital,the First School of Clinical Medicine,Southern Medical University,Nanjing 210016,China)

机构地区：[1]南方医科大学第一临床医学院(东部战区总医院),国家肾脏疾病临床医学研究中心,全军肾脏病研究所,南京210016

出　　处：《肾脏病与透析肾移植杂志》2022年第1期21-25,共5页Chinese Journal of Nephrology,Dialysis & Transplantation

基　　金：国家自然科学基金项目(81770701)。

摘　　要：目的:通过对5例抗中性粒细胞胞质抗体(ANCA)相关肾炎(AAGN)患者共7次妊娠的随访,探讨AAGN患者的妊娠合并症和胎儿结局及其影响因素。方法:5例抗髓过氧化酶(MPO)-ANCA阳性AAGN女性患者,在获得肾脏缓解后妊娠。孕期给予激素或联合硫唑嘌呤维持,血管炎活动性采用伯明翰血管炎活动评分(BVAS)评分。患者妊娠并发症包括AAGN复发、妊娠高血压、慢性肾脏病(CKD)进展或急性肾损伤;胎儿不良结局包括早产、胎儿丢失和胎儿宫内发育迟缓(IUGR)等。结果:5例AAGN患者共妊娠7次(2例患者妊娠2次)。妊娠前中位AAGN病程60(34,125)月,肾脏缓解时间32(15,75)月,尿蛋白≤0.5g/24h,估计的肾小球滤过率(eGFR)均>60 ml/(min·1.73m^(2)),4例次血清MPO-ANCA阳性(1例高滴度阳性)。孕期6例次激素治疗,1例次激素联合硫唑嘌呤。7次妊娠中4次无妊娠相关并发症,胎儿足月生产;3次出现母体并发症或不良胎儿结局(分别为孕期严重高血压并提前终止妊娠,子痫前期伴胎儿IUGR及早产,及孕前MPO-ANCA高滴度阳性者AAGN复发)。产下6个新生儿均存活。产后中位随访22月,1例产后1月AAGN复发(孕期MPO-ANCA持续低滴度阳性),1例孕期复发患者由CKD 2期进展至CKD 3期,1例孕前高血压且妊娠2次的患者由CKD1期进展至CKD 4期。结论:肾脏缓解的女性AAGN患者可以成功妊娠,但对血清ANCA阳性和高血压患者应加强干预以降低AAGN复发、肾功能恶化和妊娠不良结局的风险。Objective:To discuss the pregnancy outcomes and influence factors in patients with antineutrophil cytoplasmic antibody—associated glomerulonephritis(AAGN).Methodology:Five women with MPO-ANCA positive AAGN who achieved complete renal remission were collected in our unit.Prednisone or prednisone combined azathioprine(AZA)was administered during pregnancy.Vasculitis activity was scored by BVAS.Pregnancy-related complications included relapse of AAGN,gestational hypertension,progression of chronic kidney disease(CKD),or acute kidney injury.Adverse fetal outcomes include premature delivery,fetal loss,and intrauterine growth retardation(IUGR).Results:We described 7 pregnancies in 5 patients who were all in remission at conception,and the mean time to renal remission was 32 months.EGFR of all the patients before pregnancy was more than 60 ml/(min·1.73 m^(2)),and proteinuria was less than 0.5 g/24 h.Serum MPO-ANCA was positive in 4 pregnancies,and one with hypertension before pregnancy.Six pregnancies were maintained with prednisone monotherapy and one with prednisone combined AZA.4 of the 7 pregnancies were no pregnancy-related complications and the fetuses were delivered to term,and the other 3 pregnancies were with fetal or maternal complications(including one with severe hypertension in pregnancy and termination of pregnancy at 8 weeks,one with preeclampsia and fatal premature delivery,one experiencing a relapse during pregnancy with positive serum MPO-ANCA before pregnancy).The median follow-up after the last conception was 22 months,one patient experienced a relapse after conception,and the patient with hypertension before pregnancy progressed from CKD stage 1 to CKD stage 4.Conclusion:Patients in remission of AAGN at conception can have a successful pregnancies,but MPO-ANCA positive increases the risk of recurrence,hypertension increases the risk of fetal adverse outcomes and the progression of CKD.

关 键 词：抗中性粒细胞胞质抗体相关性肾炎 抗髓过氧化酶-抗中性粒细胞胞质抗体 妊娠结局 胎儿 

分 类 号：R714.258[医药卫生—妇产科学]