慢性肾脏病患者不良妊娠结局的危险因素分析

doi:10.3969/j.issn.1674-8115.2024.05.003

摘要/Abstract

摘要：

目的·通过对妊娠合并慢性肾脏病患者临床资料和不良妊娠结局的相关性分析，寻找导致不良妊娠结局的危险因素。方法·纳入2017年1月1日—2021年12月31日在上海交通大学医学院附属仁济医院规范产检、在该院分娩且出院诊断为妊娠合并慢性肾脏病的单胎孕产妇，采集孕20周前的临床资料。根据妊娠结局将研究对象分为不良妊娠结局组（研究组）和良好妊娠结局组（对照组）。比较2组孕产妇的临床资料、实验室检验结果、妊娠结局，分析导致不良妊娠结局的危险因素。结果·共收集了359例孕产妇的临床资料，排除双胎妊娠6例，余353例患者纳入研究。其中230例妊娠未出现相关母婴并发症，纳入对照组；123例妊娠发生了不良母婴结局，纳入研究组。研究组（1次妊娠可发生多种不良妊娠结局）包括子痫前期69例（含重度子痫前期43例）、急性肾损伤29例、早产69例、小于孕龄儿34例、低出生体质量儿46例、新生儿入住重症监护病房41例、孕20周后胎儿丢失或新生儿死亡7例。2组孕产妇在年龄、体质量指数、孕次、产次间差异均无统计学意义。慢性肾脏病患者中，妊娠20周前合并慢性高血压（OR=3.385，95% CI 1.115~10.726，P=0.031）、血肌酐超过60 μmol/L（OR=2.828，95% CI 1.439~5.557，P=0.003）、24 h蛋白尿≥0.3 g（OR=2.234，95% CI 1.122~4.448，P=0.022）、狼疮肾炎（OR=4.917，95% CI=1.967~12.290，P=0.001）患者发生不良妊娠结局的风险显著升高。联合4项指标预测慢性肾脏病孕妇发生不良妊娠结局的ROC曲线下面积为0.759，敏感度为52.8%，特异度为84.2%。结论·孕20 周前合并慢性高血压、24 h尿蛋白超过0.3 g、血肌酐超过60 μmol/L、肾炎类型为狼疮肾炎是慢性肾脏病患者发生不良妊娠结局的独立危险因素，4项指标联合对不良妊娠结局有较好的预测价值。

关键词: 妊娠, 慢性肾脏病, 不良妊娠结局, 危险因素

Abstract:

Objective ·To find out the risk factors leading to adverse pregnancy outcome by analyzing the correlation of clinical data and adverse pregnancy outcomes in patients with pregnancy complicated with chronic kidney disease. Methods ·The clinical data before 20 weeks of gestation of single pregnant patients discharged with a diagnosis of chronic kidney disease who conducted standardized prenatal examination and delivered in Renji Hospital, Shanghai Jiao Tong University School of Medicine from January 1, 2017 to December 31, 2021 were collected retrospectively. According to the pregnancy outcomes, patients were divided into adverse pregnancy outcome group (study group) and good pregnancy outcome group (control group). The clinical data, laboratory test results and pregnancy outcomes of the two groups of pregnant women were compared, and the risk factors leading to adverse pregnancy outcomes were analyzed. Results ·Maternal clinical data of 359 pregnant patients were collected, 6 cases of twin pregnancy were excluded, and the remaining 353 cases of pregnancy with chronic kidney disease were included in this study. Among them, 230 cases of pregnancy without related maternal and fetal complications were included in the good pregnancy outcome group (control group), and 123 cases of pregnancy with adverse maternal and fetal outcomes were included in the adverse pregnancy outcome group (study group). The adverse pregnancy outcome group (one pregnancy can have multiple adverse pregnancy outcomes) includes 69 cases of preeclampsia (including 43 cases of severe preeclampsia), 29 cases of acute kidney injury, 69 cases of premature delivery, 34 cases of infants smaller than gestational age, 46 cases of low birth weight infants, 41 cases of neonatal admission to NICU, and 7 cases of miscarriage after 20 weeks of gestation or neonatal death. There were no differences in age, body mass index, pregnancy times and birth times between the study group and control group. In patients with chronic kidney disease, those who had chronic hypertension (OR=3.385, 95% CI 1.115—10.726, P=0.031), serum creatinine over 60 μmol/L (OR=2.828, 95% CI 1.439—5.557, P=0.003), 24-hour urine protein≥0.3 g (OR=2.234, 95% CI 1.122—4.448, P=0.022), and lupus nephritis before 20 weeks of gestation (OR=4.917, 95% CI=1.967—12.290, P=0.001) were at significantly higher risk of adverse pregnancy outcomes. The area under the ROC curve was 0.759, the sensitivity was 52.8%, and the specificity was 84.2% for predicting adverse pregnancy outcomes in pregnant women with chronic kidney disease. Conclusion ·Chronic hypertension, 24-hour urine protein≥0.3 g, nephritis type of lupus nephritis and serum creatinine≥ 60 μmol/L before 20 weeks of gestation are independent risk factors for adverse pregnancy outcome in CKD patients. The combination of the above four indicators have a good predictive value for adverse pregnancy outcomes.

Key words: pregnancy, chronic kidney disease, adverse pregnancy outcome, risk factor

中图分类号:

R714.256

李玉, 张羽. 慢性肾脏病患者不良妊娠结局的危险因素分析[J]. 上海交通大学学报（医学版）, 2024, 44(5): 560-566.

LI Yu, ZHANG Yu. Analysis of risk factors of adverse pregnancy outcomes in patients with chronic kidney disease[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2024, 44(5): 560-566.

图/表 6

参考文献 20

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Item	Type of nephritis
Item	Chronic nephritis	IgA nephropathy	Lupus nephritis	Nephrotic syndrome
Number of delivery/n(%)	201 (56.94)	99 (28.05)	39 (11.05)	14 (3.97)
Maternal outcome/n(%)
PE	43 (21.39)	14 (14.14)	11 (28.21)	1 (7.14)
Severe PE	24 (11.94)	9 (9.09)	9 (23.08)	1 (7.14)
Acute kidney injury	13 (6.50)	10 (10.10)	3 (7.69)	3 (21.43)
Fetal outcome/n(%)
Fetal loss after 20 weeks	3 (1.49)	3 (3.03)	0 (0)	1 (7.14)
Neonatal death	0 (0)	0 (0)	0 (0)	0 (0)
Preterm birth	28 (13.93)	16 (16.16)	22 (56.41)	3 (21.43)
Preterm birth before 34weeks	9 (4.48)	7 (7.07)	10 (25.64)	3 (21.43)
LBWI	18 (8.95)	9 (9.09)	17 (43.58)	2 (14.29)
SGA	16 (7.96)	8 (8.08)	8 (20.51)	2 (14.29)
NICU	19 (9.45)	9 (9.09)	11 (28.20)	2 (14.29)

Item	Type of nephritis
Item	Chronic nephritis	IgA nephropathy	Lupus nephritis	Nephrotic syndrome
Number of delivery/n(%)	201 (56.94)	99 (28.05)	39 (11.05)	14 (3.97)
Maternal outcome/n(%)
PE	43 (21.39)	14 (14.14)	11 (28.21)	1 (7.14)
Severe PE	24 (11.94)	9 (9.09)	9 (23.08)	1 (7.14)
Acute kidney injury	13 (6.50)	10 (10.10)	3 (7.69)	3 (21.43)
Fetal outcome/n(%)
Fetal loss after 20 weeks	3 (1.49)	3 (3.03)	0 (0)	1 (7.14)
Neonatal death	0 (0)	0 (0)	0 (0)	0 (0)
Preterm birth	28 (13.93)	16 (16.16)	22 (56.41)	3 (21.43)
Preterm birth before 34weeks	9 (4.48)	7 (7.07)	10 (25.64)	3 (21.43)
LBWI	18 (8.95)	9 (9.09)	17 (43.58)	2 (14.29)
SGA	16 (7.96)	8 (8.08)	8 (20.51)	2 (14.29)
NICU	19 (9.45)	9 (9.09)	11 (28.20)	2 (14.29)

Item	Study group (n=123)	Control group (n=230)	P value
Age/year	31.22±3.74	31.37±3.64	0.723
BMI/(kg·m^-2)	22.74±3.57	21.92±2.89	0.058
Pregnancy/n	2 (1, 3)	2 (1, 2)	0.268
Delivery/n	0	0	0.630
Chronic hypertension/n(%)	20 (16.26)	19 (8.26)	0.022
SBP/mmHg	123 (115, 132)	115 (108, 123)	0.000
DBP/mmHg	79 (71, 86)	71.5 (66, 80)	0.000
MAP/mmHg	94 (86, 101)	86 (80, 93)	0.000
Aspirin/n(%)	109 (88.61)	200 (86.96)	0.653
Immunosuppressant/n(%)	38 (30.89)	33 (14.35)	0.000
24 h proteinuria≥0.3 g/n(%)	70 (56.91)	79 (34.35)	0.000
24 h proteinuria≥2 g/n(%)	57 (46.34)	31 (13.48)	0.000
Types of nephritis/n(%)
Chronic nephritis	68 (55.28)	133 (57.83)	0.646
IgA nephropathy	27 (21.95)	72 (31.30)	0.062
Nephrotic syndrome	4 (3.25)	10 (4.35)	0.615
Lupus nephritis	24 (19.51)	15 (6.52)	0.000

Item	Study group (n=123)	Control group (n=230)	P value
Age/year	31.22±3.74	31.37±3.64	0.723
BMI/(kg·m^-2)	22.74±3.57	21.92±2.89	0.058
Pregnancy/n	2 (1, 3)	2 (1, 2)	0.268
Delivery/n	0	0	0.630
Chronic hypertension/n(%)	20 (16.26)	19 (8.26)	0.022
SBP/mmHg	123 (115, 132)	115 (108, 123)	0.000
DBP/mmHg	79 (71, 86)	71.5 (66, 80)	0.000
MAP/mmHg	94 (86, 101)	86 (80, 93)	0.000
Aspirin/n(%)	109 (88.61)	200 (86.96)	0.653
Immunosuppressant/n(%)	38 (30.89)	33 (14.35)	0.000
24 h proteinuria≥0.3 g/n(%)	70 (56.91)	79 (34.35)	0.000
24 h proteinuria≥2 g/n(%)	57 (46.34)	31 (13.48)	0.000
Types of nephritis/n(%)
Chronic nephritis	68 (55.28)	133 (57.83)	0.646
IgA nephropathy	27 (21.95)	72 (31.30)	0.062
Nephrotic syndrome	4 (3.25)	10 (4.35)	0.615
Lupus nephritis	24 (19.51)	15 (6.52)	0.000

Item	Study group (n=123)	Control group (n=230)	P value
WBC/(×10⁹·L^-1)	9.57±2.62	9.19±2.29	0.158
HB/(g·L^-1)	120.22±18.49	123.69±11.71	0.061
PLT/(×10⁹·L^-1)	237.97±66.47	238.05±54.92	0.990
TSH/(mIU·mL^-1)	1.52 (0.71, 2.74)	1.31 (0.53, 2.00)	0.092
Serum creatinine/(μmol·L^-1)	58.00 (44.00, 82.00)	48.25 (42.77, 53.85)	0.000
Proteinuria/[mg·(24 h)^-1]	683 (326, 2 121)	321 (177, 691)	0.000