肾移植术后妊娠九例十次临床分析

目的探讨肾移植受者术后妊娠、分娩的安全性和可行性。方法回顾性分析1997年1月至2014年6月在温州医科大学附属第一医院行肾移植术后成功妊娠并分娩的9例受者临床资料。9例受者移植时平均年龄(26±4)岁,8例为尸体肾移植,1例为活体肾移植;原发病均为慢性肾小球肾炎,其中2例为Ig A肾病。9例受者共自然受孕12次,成功妊娠并分娩10次,流产2次;成功妊娠时平均年龄(31±6)岁,妊娠距肾移植时间平均(78±46)个月。观察受者妊娠前3个月、妊娠早、中、晚期和分娩后3个月移植肾功能、免疫抑制剂血药浓度、母体和胎儿并发症以及子代生长发育等相关情况。结果妊娠前3个月,受者平均血清肌酐和估算肾小球滤过率(e GFR)分别为(68±12)μmol/L和(94±18)m L·min-1·(1.73 m2)-1,妊娠早、中期血清肌酐分别为(66±13)、(62±13)μmol/L,妊娠早、中、晚期e GFR分别为(99±19)、(114±24)、(112±26)m L·min-1·(1.73 m2)-1,与妊娠前相比,差异均有统计学意义(P均0.05)。妊娠前环孢素血药浓度谷值为(43±13)ng/m L,妊娠中期下降至(31±14)ng/m L,差异有统计学意义(P0.05);他克莫司血药浓度和剂量变化差异均无统计学意义。2例受者妊娠期间出现子痫前期,1例为轻度,1例为重度;6例并发泌尿系统感染,未发生急性排斥反应。10例胎儿平均孕周为(37.4±2.0)周,其中早产2例;出生体重中位数为3 005 g,其中低体重儿1例;1 min Apgar评分除1例为9.5分,其余均为10.0分。截至2017年7月,子代年龄为3个月至17岁,其智力、体格发育和学习能力等方面均无异常,未发生免疫系统缺陷或注意力缺陷多动障碍等。结论肾移植术后妊娠对于母体及胎儿均有风险,但是选择合适的受孕时机,适当调整免疫抑制方案,围产期严密监测,能提高肾移植术后妊娠的安全性。     

女性肾移植受者术后生育22例报告

目的 探讨女性肾移植受者术后生育对子代、移植肾及自身健康的影响.方法 回顾分析8个器官移植中心自1989年8月至2007年2月的资料,共有22例女性肾移植受者术后妊娠,并各生育子女1名.由专人负责收集、整理受者及其子女的资料,包括受者的年龄、病程、肾移植时间、免疫抑制剂的应用、结婚及孕产时间、妊娠和分娩情况、子女出生情况、喂养方式等,并对其中的18名子女进行了体格检查,记录其身高和体重.结果 22例生育时的年龄为(27.8±2.7)岁,分娩时间为术后(35.1±13.2)个月,孕产期问免疫抑制方案为环孢素A(或他克莫司)、硫唑嘌呤(或霉酚酸酯)和泼尼松联用.其中21例为剖宫产,1例为自然分娩;6名(27.3%)为早产,其余为足月产.22名子女出生时体重为(2944±585)g,均人工喂养,现年龄最大者为18岁,最小者为8个月.3岁、4岁和5岁者的体重分别为(15.2±1.3)kg、(17.0±0.9)kg和(17.8±0.4)kg,身高分别为(99.0±3.6)cm、(106.4±1.3)cm和(109.5±0.7)cm,其他年龄段因样本数太少,未行统计.未发现明显畸形.22例受者在孕产期间并发高血压9例次,肾功能异常和蛋白尿各5例次,肺部感染和心力衰竭各4例次,尿路感染3例次,6例移植肾功能丧失,2例因肺部感染、心力衰竭死亡,1例因慢性排斥反应、移植肾功能丧失、心力衰竭死亡.结论 女性肾移植受者术后若情况允许,可以生育,但有时可对移植肾及自身健康有一定的影响,整个妊娠、生育过程应有产科、移植科以及心内科等医生共同参与指导.     

肾移植术后妊娠五例六次

目的 探讨肾移植术后妊娠对受者及移植肾的影响.方法 回顾性分析5例6次肾移植术后妊娠的临床资料.结果 受者妊娠时平均年龄为31.1岁,移植至妊娠的时间平均为3.6年.5例6次妊娠中发生先兆子痫2例次,高脂血症1例次.最终成功分娩4例,分别于38周、35周、35周和38周接受剖宫产,新生儿平均体重为3262.5 g,新生儿Apgar评分均为10分.2例次因减少或停用免疫抑制剂,移植肾功能丧失而终止妊娠,其中1例接受再次肾移植后再次妊娠并成功分娩.结论 对于移植肾功能正常的女性受者,在合理应用免疫抑制剂的前提下妊娠和分娩是可行的,但具有较高风险,需要严密监护.     

低龄心脏停跳供者单个肾脏成人移植11例

目的 总结符合脑死亡诊断标准的低龄患儿心脏停跳后供肾应用于成人移植的处理经验.方法 心跳停止后单个供肾患儿6例,月龄49～106(75.35±22.8)个月,体质量16.6～37.8(23.9±8.4)kg.受者11例,平均年龄(28.2±7.9)岁,体质量(46.9±4.2)kg.单个供肾植入受者右侧髂窝.手术方法同成人尸肾移植.术中开始单/多克隆抗体加甲泼尼龙诱导治疗,术后常规环孢素或他克莫司、霉酚酸酯、泼尼松三联免疫抑制剂治疗.结果 受者肾功能均恢复正常,其中出现移植肾功能延迟恢复3例.术后移植肾增大明显,灌注后和移植后1周移植肾长径分别为(70.6±5.5)和(86.1±6.9)mm(P＜0.001),之后移植肾持续缓慢增大,至术后12个月移植肾长径为(104.5±8.8)mm.平均随访时间(21.8±9.5)个月,1年人/肾存活率均为100%.结论 低龄心跳停止供者单个供肾植入低体重的成人受者,可以成功维持受者正常肾功能,1年人/肾存活率与成人尸肾移植无显著差异.     

肾移植受者妊娠期CNI血药浓度变异性对移植肾功能及妊娠和胎儿的影响

目的观察肾移植受者妊娠期CNI血药浓度变异性对移植肾功能及妊娠和胎儿的影响。 方法回顾性分析1997年1月1日至2019年6月30日在温州医科大学附属第一医院行肾移植手术的育龄期女性受者术后妊娠情况，共有14例肾移植受者术后成功妊娠并分娩15次，均为自然受孕。自怀孕前3个月至分娩后3个月，受者每月随访监测CNI剂量和血药浓度、血清肌酐和估算肾小球滤过率，并根据CNI血药浓度谷值计算变异系数(CV)。观察受者妊娠和胎儿并发症发生情况及新生儿情况，分析CV与移植肾功能和妊娠并发症的相关性。采用重复测量方差分析比较受者妊娠前后各时间点CNI血药浓度、血清肌酐和eGFR水平及CV，进一步两两比较采用LSD法。采用成组t检验或χ²检验比较妊娠晚期高CV和低CV受者妊娠年龄、移植妊娠间期、移植肾功能不全、先兆子痫和胎儿早产情况。P<0.05为差异有统计学意义。 结果14例受者成功妊娠年龄(31±5)岁(21～39岁)，移植妊娠间期平均(71±43)个月(22～157个月)。14例受者CNI血药浓度妊娠后逐渐下降，妊娠中期最低；CV在妊娠早期最高，为(45±30)%，与妊娠前、妊娠中期和晚期相比差异均有统计学意义(P均<0.05)。妊娠过程中，血清肌酐先下降后上升，妊娠中期降至最低，为(62±11)μmol/L，与妊娠前相比差异有统计学意义(P<0.05)。1例受者妊娠过程中出现无症状蛋白尿(尿蛋白＋＋)，分娩后转阴。3例受者分别于分娩后7个月、10个月和9年出现移植肾功能不全。14例肾移植受者妊娠过程中有2例出现先兆子痫，1例在分娩后即缓解，1例在分娩后4个月缓解；4例受者发生泌尿系统感染，予碱化尿液及增加饮水量后均好转。分娩方式包括自然分娩2例，剖宫产13例。15例新生儿中，1例为低体重儿，2例早产儿胎龄分别为32周和36周4天。妊娠晚期CNI血药浓度高CV受者移植肾功能不全及早产发生比例高于低CV受者，差异均有统计学意义(χ²＝5.104和9.231，P均<0.05)。 结论肾移植术后妊娠早期CNI血药浓度CV明显升高，妊娠晚期CNI血药浓度CV>50%的肾移植受者可能更容易发生早产和移植肾功能不全。     

成人供肾双肾移植的临床疗效

目的探讨成人供肾双肾移植(DKT)的临床疗效。方法回顾性分析2016年9月至2020年12月中南大学湘雅二医院收治的13例成人供肾DKT手术供受者的病例资料。13例供者年龄(53.5±12.4)岁, 体质量指数(BMI)(24.3±2.8)kg/m2, 3例有糖尿病史, 8例有高血压病史。13例中, 11例符合美国器官共享联合网络(UNOS)双肾移植标准, 6例符合Remuzzi评分双肾移植标准, 入院时和获取供肾前血清肌酐(SCr)分别为(132.9±54.1)μmol/L和(228.7±112.4)μmol/L。13例受者年龄(39.3±8.9)岁, BMI(20.2±2.4)kg/m2。所有受者均接受ABO血型相合的肾移植, 2例双肾分别放置于双侧髂窝。12例移植肾开放血运后颜色鲜红、充盈迅速, 输尿管立即可见尿液流出, 1例双肾颜色偏暗, 血管搏动弱。记录受者围手术期移植肾功能恢复时间(从手术当天至SCr自然降至正常范围的时间)、移植肾功能延迟恢复(DGF)、急性排斥(AR)、输尿管并发症、手术切口并发症情况, 以及受者末次随访时的SCr、估算肾小球滤过率(eGFR)、尿蛋白和...     

儿童肾移植138例分析

目的 总结多个移植中心138例儿童肾移植的治疗效果.方法 回顾性分析8个移植中心自1986年3月至2010年5月间138例儿童肾移植的临床资料.受者年龄为(13.8±1.4)岁,其中男性92例,女性46例.138例均随访观察1年以上.初始免疫抑制方案均为以钙调磷酸酶抑制剂为主的三联方案,部分受者应用抗体诱导治疗.结果 术后1年受者和移植肾存活率分别为99.3％和95.7％.术后38例(27.5％)发生急性排斥反应,15例出现移植肾功能恢复延迟,但均在1个月内恢复.其他并发症为移植肾动脉狭窄8例,尿瘘5例,输尿管坏死2例,高血压57例,高脂血症38例,多毛症32例,药物性肝损伤26例,尿路感染25例,牙龈增生22例,肺部感染21例,骨髓抑制12例,单纯性疱疹10例,糖尿病8例.受者术后1年体重增加4～13 kg,身高增加2～7 cm.结论 细致地围手术期处理,免疫抑制剂的合理应用,加强随访,提高受者服药依从性是儿童肾移植获得良好效果的关键.     

致敏患者经双滤过法血浆分离方案预处理后行肾移植的临床效果分析

目的 分析致敏患者经双滤过法血浆分离(DFPP)方案预处理,并联合使用抗CD25单抗诱导治疗后行肾移植的临床效果和安全性.方法 回顾性分析2000年11至2012年1月45例致敏受者在肾移植前经DFPP方案预处理,并联合使用抗CD25单抗诱导治疗后接受肾移植的临床资料.所有受者预处理前的群体反应性抗体(PRA)水平均大于20％,为(56.5±19.9)％,预处理后PRA水平降至(18.9±19.1)％.受者与供者的HLA抗原错配数为(2.1±0.7)个,术前2次供、受者淋巴细胞毒交叉配型试验均为阴性.所有受者术后至少随访1年,观察术后1年受者和移植肾存活率,以及排斥反应和肺部感染的发生情况.结果 随访期间,无受者死亡,有2例受者发生移植肾功能丧失,术后1年受者存活率为100％(45/45),移植肾存活率为95.6％ (43/45).术中肾血管开放后1例发生超急性排斥反应,发生率为2.2％,受者在切除移植肾后恢复血液透析;术后发生急性排斥反应12例,发生率为26.7％(12/45),经甲泼尼龙和(或)ATG冲击治疗后,11例完全逆转,1例出现移植肾功能丧失而恢复血液透析.术后肺部感染发生率为8.9％(4/45),经抗感染治疗后均好转,未发生重症肺部感染.结论 肾移植前采用DFPP 预处理,并联合使用抗CD25单抗诱导治疗安全有效,能使致敏受者获得良好的肾移植效果.     

低龄婴儿双供肾移植给成人22例报道

目的总结单中心低龄婴儿双供肾移植给成人的临床效果。方法回顾性纳入2013年7月至2017年10月华中科技大学同济医学院附属同济医院实施的所有儿童双供肾移植给成人受者共22例临床资料和随访数据。22例供者年龄(2.9±1.7)个月,体重(4.9±1.4)kg,其中15例小于3月龄。受者多为低体重女性成人,体重(46.3±5.6)kg。总结早期移植失败及随访期间移植肾失功或受者死亡原因。根据是否发生单侧移植肾血栓,移植肾功能恢复者又进一步分为双肾存活组和单肾存活组,比较移植肾中-长期功能。结果4例受者在术后早期出现移植失败,包括双肾血栓2例、移植肾破裂切除1例和受者多器官功能衰竭死亡1例。18例受者移植肾功能恢复出院,随访期间因移植肾新生肿瘤切除双肾1例、因复杂全身原因死亡1例、因间质性肺炎死亡1例,余15例受者双肾均存活者10例(中位随访59个月),单肾存活者5例(中位随访48个月)。移植1年时双肾存活组估算肾小球滤过率为(95±27)ml/(min·1.73 m2),显著高于单肾存活组(61±24)ml/(min·1.73 m2)(P<0.05),但3年时分别为(95±21)ml/(min·1.73 m2)和(69±31)ml/(min·1.73 m2),差异缩小,差异无显著统计学意义(P=0.12)。结论低龄婴儿双供肾移植虽然可以扩大供肾来源,但发生早期移植失败和单肾栓塞的风险较高。在单肾存活的情况下,受者仍具有相对满意的中-长期移植效果。     

肾移植术后妊娠对移植肾的影响

目的 探讨肾移植术后妊娠对移植肾的影响。方法 对1978年4月至2002年3月妊娠超过5个月的13例肾移植受者资料进行回顾性分析。结果 免疫抑制方案，4例采用环孢素A（CsA)及泼尼松（Pred)。5例为CsA，霉酚酸酯（MMF）及Pred。4例为他他克莫司（FK506），MMF及Pred。13例中，10例患者妊娠足月，生产，母，婴均存活，移植肾功能稳定；1例产后2周因并发肺部感染，心力衰竭死亡，死亡时移植肾有功能，婴儿存活；2例妊娠中期出现蛋白尿，病理证实移植肾发生慢性排斥反应，终止妊娠，但抗排斥治疗无效，切除移植肾，恢复血液透析，目前11名子女健康，无发育异常。结论 肾移植患者若情况允许，在严重监护下是可以妊娠的。     

Outcome of 234 pregnancies in 140 renal transplant recipients from five middle eastern countries

OBJECTIVE: To study the pregnancy and offspring outcomes in postrenal transplant recipients. METHODS: This is a retrospective case-note review study investigating the outcome of 234 pregnancies in 140 renal transplant recipients from five different Middle Eastern countries. RESULTS: Of the overall pregnancies 74.4% were successful albeit with high prevalences of preterm and Caesarean deliveries (40.8% and 53%, respectively). The mean serum creatinine did not rise significantly during pregnancy in the group as a whole but did so in patients who had serum creatinine of or above 150 micromol/L at the beginning of their pregnancies. The mean birth weight was (2,458 g) with 41.3% of the newborns being of low birth weight (<2,500 g). The prevalences of stillbirths were 7.3% and of spontaneous abortion was 19.3%. Preeclampsia and gestational diabetes were observed in 26.1% and 2% of pregnancies, respectively. CONCLUSIONS: In the presence of good allograft function, the majority of pregnancies in renal transplant recipients have a good outcome but with increased incidence of preeclampsia, reduced gestational age, and low birth weights. Patients with baseline serum creatinine of above 150 micromol/L have an increased risk of allograft dysfunction resulting from the pregnancy.     

Transplantation of kidneys from children

During an 11-year period from 1978 to 1988, 720 cadaver kidneys were transplanted at the University Hospital of Zurich. 103 of the kidney grafts were from donors 16 years old or younger. The mean age of these donors was 11 years (range 2 1/3 to 16 years). There were 3 donors under 5 years, where we preserved and transplanted both kidneys en bloc. Only 3 recipients were less than 16 years old. After 1 year, 67 out of 103 recipients had a functioning pediatric graft. In the cyclosporine-treated group, the 1-year graft survival was even 80%, similar to kidney transplants from adult donors. Graft loss was observed in 48 cases. 33 patients rejected the transplant and 10 grafts were lost after recurrence of the primary renal disease. Only 5 grafts had a vascular complication. We conclude that kidneys from pediatric donors can successfully be transplanted into adults.     

Pregnancy in kidney transplantation: satisfactory outcomes and harsh realities

Since the first successful case of a pregnancy reported 40 yrs ago in a woman receiving a kidney transplant from her identical twin sister who did not receive immunosuppressive medications, the dream of a pregnancy in a renal transplant recipient has become reality. In women of childbearing age with a functioning transplant, the pregnancy rate has improved from 2 to 5%. Approximately 35% of pregnancies do not progress beyond the 1st trimester; the success rate is > 90% after the 1st trimester. In this review, different aspects of this topic are discussed: the consequences of pregnancy on renal grafts and maternal morbidity (hemodynamic changes, immunological problems, hypertension/preeclampsia, urinary tract infections and renal damage progression), the influence of renal grafts on pregnancy (perinatal mortality, prematurity, intrauterine growth retardation, low birth weight, malformations, handicaps and immunological problems) and the role of drugs used for renal transplants. A pregnancy can have a successful outcome if pre-conceptional graft function is good, if hypertension is absent and if the interval from grafting is at least 2 yrs. However, the majority of live-born outcomes are premature and many are low birth weight. Recipients must be advised that their offspring can also suffer from immunological abnormalities, malformations, long-term handicaps, and that the deleterious effects of pregnancy on long-term graft function cannot be excluded. In conclusion, women of childbearing age who have had renal transplantation should be counselled before conception about possibility and risks of pregnancy.     

Pregnancy in women receiving renal dialysis or transplantation in Japan: a nationwide survey.

BACKGROUND: Since a report on the first successful pregnancy of a woman on long-term haemodialysis in Japan in 1977, there has been a growing number of case reports on successful pregnancy in patients on dialysis. We undertook a nationwide survey on pregnancy in women on renal replacement therapy in 1996. METHODS: A preliminary questionaire was sent to 2504 dialysis units and 143 renal transplant units in Japan. For each reported pregnancy, a more detailed questionaire was sent to collect nephrological, obstetric and neonatal information. RESULTS: There were 172 pregnancies (0.44%) reported in 38889 women on dialysis, with 90 successful pregnancies (0.23%), and 194 pregnancies reported in 852 female renal transplant recipients. Detailed pregnancy information was collected from 74 women on dialysis and 194 renal transplant recipients. Of the 74 pregnancies in the women on dialysis, 36 (48.6%) resulted in surviving infants, nine (12.2%) in neonatal death, nine (12.2%) spontaneous abortions and 14 (18.9% elective abortions were reported. The outcome of six pregnancies (8.1%) was unknown. Of 194 pregnancies in renal transplant recipients, 159 (82.0%) resulted in surviving infants, two (1.4%) in neonatal death and 28 (14.4%) in spontaneous or elective abortion. In five cases the pregnancy outcome was not reported. No congenital anomalies were reported, except two infants with mental retardation and one with epilepsy. CONCLUSION: The current survey revealed that the rate of successful pregnancy in women on dialysis has improved. More than half of the pregnancies resulted in infant survival. But, premature birth is a major problem for the children of women on dialysis and there is a higher rate of neonatal death. There are significant differences in gestational age, birth weight, frequency and severity of prematurity and rates of neonatal death between pregnancies of women undergoing dialysis and those who are renal transplant recipients.     

Pregnancy under everolimus-based immunosuppression

The ability to give birth to a live child is one of the best success of kidney transplantation. While there are an increasing number of pregnancies reported in kidney transplant recipients treated with cyclosporine or tacrolimus, there is little evidence of pregnancy among kidney transplant recipients exposed to sirolimus or everolimus. We present the first successful delivery in an organ transplant recipient exposed to everolimus during the whole gestation. The absence of congenital anomalies in the child as well as the recipient's successful renal outcome are promising, although pregnancy in renal transplant recipients exposed to everolimus should be considered at higher risk.     

Sirolimus used during pregnancy in a living related renal transplant recipient: a case report

OBJECTIVES: The majority of pregnancies after transplantation reported in the literature occurred in patients treated with a combination of calcineurin inhibitors, prednisolone, and azathioprine. There is little experience with newer drugs. We report a successful pregnancy in a kidney recipient with exposure to sirolimus-based immunosuppression. METHODS: We describe a case of successful delivery in a 30-year-old woman who became pregnant 1 year and 8 months after a living related renal transplantation. She received sirolimus, cyclosporine, and prednisolone before conception and during the first and second trimesters of gestation. RESULTS: The female recipient received sirolimus in combination with cyclosporine and prednisolone. During follow-up, her serum creatinine values were stable with pregnancy occurring at 1 year and 8 months after transplantation. At 27 gestational weeks, sirolimus was discontinued and she was maintained on cyclosporine and prednisolone. There were no signs or symptoms of graft rejection. A Cesarean section was performed at 39 weeks of gestation to deliver a healthy, 2994-g, Apgar 10, male infant. The renal function of the female recipient continued to be stable after delivery. CONCLUSION: To date, pregnancies in renal transplant recipients are still considered high risk. The U.S. National Transplantation Pregnancy Registry (NTPR) has reported increased rates of maternal and fetal complications. There have been no live births reported to the NTPR about female recipients exposed to sirolimus throughout gestation. We report a live birth without a structural defects with successful delivery after sirolimus use during the first and second trimesters of gestation.     

Influence of pretransplant pregnancy on survival of renal allografts from living donors

BACKGROUND: The presence of a small number of cells of donor origin in organ transplant recipients (microchimerism) may influence allograft survival and may induce tolerance. Postpartum women may be microchimeric to offspring hematopoietic cells up to 27 years. We hypothesized that mothers receiving renal allografts from offspring would have better graft survival compared with either fathers receiving allografts from offspring, or mothers receiving allografts from nonoffspring donors. METHODS: We analyzed 1803 living related kidney transplants from the UNOS database performed between January 1, 1990, and December 31, 1995, for mothers and fathers who received grafts from offspring with one haplotype match. We also compared these mothers with parous females receiving a kidney from nonoffspring donors (spouse and other biologically related or unrelated family members). A multivariate logistic regression method was used to analyze the effect of donor type, as well as other recipient, donor, and transplant characteristics, on graft and patient survival. RESULTS: Mothers receiving one haplotype-matched offspring renal allografts did not have better graft survival at 1 or 3 years posttransplant compared with fathers receiving similar grafts. There was also no difference in graft or patient survival between mothers receiving kidney grafts from either offspring or nonoffspring donors. Graft survival in mothers with multiple pregnancies was poorer than those with a single pregnancy. CONCLUSIONS: It is possible that persistent microchimerism of fetal cells in maternal circulation may, for some mothers, cause a detectable improvement in graft or patient survival. Comparison of female and male recipients from the UNOS database did not reveal any differences in outcomes. If mothers are tolerant to their offspring, our results indicate that this microchimerism may not improve renal allograft or patient survival in offspring donor to maternal recipient combinations. Lastly, more sensitive pretransplant cross-match assays may need to be implemented in multiparous women, given our results.