신장이식 여성의 임신 예후

김대진(Dae Jin Kim),유혜경(Hye Kyung Yoo),원혜성(Hye Sung Won),구자남(Ja Nam Gu),이필량(Pil Ryang Lee),이인식(In Sik Lee),김암(Ahm Kim),박수길(Soo Gil Park),한덕종(Deok Jong Han),목정은(Jung Eun Mok) 대한산부인과학회 1999 Obstetrics & Gynecology Science Vol.42 No.8

목적: 신장이식을 받은 여성에서 임신 예후에 영향을 미치는 임신 전 및 임신 중의 요인들을 확인하고자 한다. 연구방법: 1996년 6월부터 1998년 2월까지 서울중앙병원에서 신장이식을 받고 임신이 된 모든 환자의 병록지를 후향적으로 검토하여 임신 전, 임신 중 및 출산 또는 유산 후 결과를 조사하였다. 결과: 신장이식을 받은 환자들 중 13명에서 17례의 임신이 이루어졌으며, 각 임신의 결과는 만삭분만 7례, 조산 4례, 자연유산 2례, 치료적 유산 또는 임신중절이 4례였다. 한 환자를 제외하고는 모든 환자가 임신 전후로 cyclosporin A, azathioprine 및 prednisolone으로 면역억제 치료를 받았다. 신장이식 후 임신되기까지의 평균기간은 28.8±14.3개월(범위, 6-60개월)이었다. 생존아를 출산한 11례에서 출산시 평균 임신주수는 37.7±1.2주였고 평균 출생체중은 2.85±0.37킬로그램이었으며, 5분 Apgar 수치는 모두 8 이상이었다. 이들에게서 나타난 산과적 합병증으로는 임신성 고혈압 6례(55%), 임신으로 악화된 고혈압 2례(18%), 태아발육지연 1례(9%) 및 조산 4례(36%)였다. 제왕절개술은 4례(36%)에서 시행되었는데, 3례는 기왕 제왕절개술의 병력이, 1례는 조절이 되지 않는 고혈압이 적응증이었다. 신생아 합병증으로는 일시적인 신생아 빈호흡증이 1례 있었다. 임신 전 신장이식 거부반응이 4례 있었으며, 3례는 조산이 되었고 1례는 치료적 유산을 시행하였다. 임신 전에 신장의 기능이 정상이었던 경우에는 임신기간과 출산 또는 유산 후 6-58개월간의 추적기간 중에도 신장 기능이 정상을 유지하였다. 임신 중 신장이식 거부반응이나 소실은 없었다. 결론: 신장이식을 받은 여성들 중 임신을 원하는 경우에는 비록 고혈압 등의 임신과 관련된 합병증의 빈도가 비교적 높게 나타나기는 하나 성공적인 임신 예후를 기대할 수 있을 것으로 판단되었다. 따라서 이들 신장이식 환자에 대하여 그들의 신장 기능이 정상 범위를 유지하는 경우에는 임신 및 출산을 권할 수 있을 것으로 사료된다. Objective : To assess the pre-pregnancy and pregnancy factors influencing pregnancy outcome in renal transplanted women Materials and Methods : This retrospective study included all pregnancies in renal transplanted women in Asan Medical Center between June 1996 and February 1998. We collected data from the medical records of allograft recipients. Pre-pregnant status and pregnancy outcome were described. Results : Seventeen pregnancies in 13 allograft recipients resulted in 7 term deliveries, 4 preterm births, 2 spontaneous abortions, and 4 therapeutic abortions. All but one patient received immunosuppressive therapy with cyclosporin A, azathioprine, and prednisolone during pregnancy. The mean interval from the time of transplantation to conception was 28.8±14.3 months(range 6-60 months). In live birth group, the mean gestational age at delivery was 37.7±1.2 weeks and the mean birth weight of their offspring was 2.85±0.37 kilogram. Apgar scores at 5 minutes were 8 or more in all of them. The obstetric complications were distributed as follows: pregnancy induced hypertension in 6 cases(55%), pregnancy aggravated hypertension in 2 cases(18%), fetal growth restriction in 1 case(9%), prematurity in 4 cases(36%). Cesarean sections were done in 4 cases(36%) because of previous Cesarean section(3 cases) and uncontrolled hypertension(1 case). Neonatal complication, transient tachypnea of the newborn, was found in one case. Graft rejection after transplantation occurred in 4 cases: 3 cases in preterm births and 1 case in therapeutic abortions. Maternal renal functions were normal during pregnancy and postpartum period whose pre-pregnant renal functions had been normal. No patient experienced any rejection episode or graft loss during pregnancy. Conclusion: Successful pregnancy can be expected in women with a renal transplant, although there was high incidence of pregnancy-related complications, especially hypertensive disorders. Pregnancy can be encouraged to these allograft recipients if they have good renal function.

서울중앙병원 신장이식의 임상적 분석

김지훈,박정식,박수길,장상필,김송철,한덕종,정해혁,이준승 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.6

From June 1990 to December 1998, 792 kidney transplantations were performed at Asan Medical Center. 436 cases(55M) were from living-related donors, 139 cases(17.6%) were from living-unrelated donors and 217 cases(27.4%) were from cadaveric donors. The results of the trasnplantation were analyzed according to the various factors known to influence the outcome of transplantation. In living transplants, the overall patients survival rate was 98.2% at 1 year and 95.8% at 5 years, the corres-ponding allograft survival rate was 96.9 and 86.1%. In cadaveric transplants, the overall patients survival rate was 94.3% at 1 year and 94.3% at 5 years, the corresponding allograft survival rate was was 90.296 and 84.8%. In living transplants, donor age($gt;50yrs), recipient age($gt;50yrs), ABO compatability, pretrans-plant blood transfusion, diabetic history had no effect on allograft survival rate. But HLA DR cornpa-tability, serum creatinine(2.5mg/dL) at discharge and rejection history had effect on allograft survival(p$lt;0.05). In living-related transplants, 5 year allograft survival rate was 100% at HLA identical group and 86% at HLA haplomatched group. But the statistical significance was not found(p=0.052). In cadaveric transplants, donor age($gt;50yrs), recipient age($gt;50yrs), ABO compatability, HLA DR match, diabetic history, pretransplant transfusion had no effect on allograft survival. But serum creatinine at discharge( $gt;2.5mg/dL) and posttransplant rejection had effect on allograft survival.

생체 신 이식에서 과여과와 관련된 인자가 예후에 미치는 영향

이미숙,김지훈,박정식,김유미,장상필,박종하,한덕종,정해혁 대한신장학회 1999 Kidney Research and Clinical Practice Vol.18 No.5

It is well known that immunologic factors like rejection episode and HLA missmatch influence allograft loss and prognosis. However, non-immunologic factors such as glomerular hyperfiltration may also have an effect on the survival of the allograft. We measured relative kidney function(dkRF) by DMSA scan, GFR(dGFR) using EDTA and CCr dCCr) by 24-hour urine collection in donors of 70 adult living-related renal allografts engrafted at a single center between December 1992 and January 1994 as a donor work-up before transplantation, and calculated donated kidney GFR(dkGFR=dGFRxdkRF) and CCr(dkCCr=dkCCrxdkRF). We observed graft function for 5 years and analyzed the prognostic factors for the graft. Graft dysfunction was defined as the increase of serum creatinine 5 years after transplantation more than 1.5 times of stabilized serum creatinine at 3 months after transplantation. 1) Sixty patients were followed up for 5 years. Graft dysfunction was observed in 22 patients(37%) and maintenance renal replacement therapy was required in 9(15%) of them. 2) Of the non-immunologic factors, donor age was older in patients with graft dysfunction(51±12 years) than those without it(34±11 years, p$lt;0.01), but dkGFR(54.1±12.2ml/min vs. 58.5±11.9mVmin), dkCCr(44.8±14.3mVmin vs. 50.7±13.4ml/min) and the ratio of body surface area(recipient/donor, 0.96±0.14 vs. 0.99±0.12) were not different in the two groups. Age of recipients and occurrence of graft glomerulopathy also were not different in the two groups. The episode of acute rejection was more frequent in patients with graft dysfunction(32%, 7/ 22) than those without it(3%, 1/38, p$lt;0.01), but the degree of HLA missmatch was not different. In multivariate analysis, donor age(p$lt;0.01) and the episode of acute rejection(p$lt;0.05) were independent factors affecting graft dysfunction. 3) Donor age was older(52±12 vs. 3814 years, p$lt;0.01) and the episode of acute rejection was more frequent(56%, 5/9 vs. 696, 3/51, p$lt;0.01) in 9 patients with graft loss than those without it. However, dkGFR, dkCCr, body surface area ratio, recipient age, occurrence of glomerulopathy and HLA missmatch were not different. In multivariate analysis, donor age(p$lt;0.05) and the experience of acute rejection(p$lt;0.01) were independent factors affecting graft loss. We therefore conclude that donor age is more important as non-immunologic prognostic factors in graft dysfunction than GFR of the donated kidney and the difference in body mass between recipient and donor.