Avaliação de desfechos maternos e fetais na gravidez em pacientes com glomerulopatias
Data
2023-05-30
Autores
Santos, Davi Rettori Pardo dos 
Orientadores
Kirztajn, Gianna Mastroianni
Tipo
Dissertação de mestrado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
INTRODUÇÃO: Estima-se que globalmente 6% das mulheres em idade fértil tenham
doença renal crônica (DRC) e que 3% das gestações ocorram em portadoras dessa
condição. A gravidez fisiologicamente promove aumento em volume plasmático
circulante, fluxo plasmático renal e taxa de filtração glomerular, assim como
alterações em permeabilidade capilar glomerular e reabsorção tubular e, portanto,
constitui um importante aumento na demanda metabólica renal, e a incapacidade de
adequar-se a ela está relacionada a desfechos maternos e fetais desfavoráveis. As
glomerulopatias são etiologia importante de DRC e desfechos desfavoráveis são
associados a gestações que coexistem com essa condição, especialmente em
situações de alteração de função renal prévia e proteinúria; no entanto, essa
associação carece de maior estudo, especialmente em âmbito nacional.
OBJETIVOS: Os objetivos primários deste estudo foram: descrever as
características clínicas e laboratoriais das glomerulopatias no curso da gestação e
avaliar os desfechos maternos e fetais na gravidez em pacientes com
glomerulopatias. Os objetivos secundários foram: determinar fatores associados aos
desfechos maternos e fetais na gravidez dessas pacientes. MÉTODOS: Trata-se de
um estudo observacional retrospectivo analítico do tipo coorte histórica, realizado em
centro único, baseado no levantamento de dados de prontuários de pacientes
seguidas no Ambulatório de Nefrites da UNIFESP-EPM, no período de 1992 a 2021.
RESULTADOS: Avaliamos 60 gestações que preenchiam os critérios de inclusão. A
idade média das pacientes era de 28,7 anos; o diagnóstico etiológico da
glomerulopatia correspondia em frequência decrescente a nefrite lúpica (31,7%),
glomeruloesclerose segmentar e focal (GESF, 26,7%), doença de lesões mínimas
(16,7%), nefropatia por IgA (8,3%), doença de Alport (6,7%), glomerulopatia
membranosa (3,3%), nefropatia por C1q (1,7%) e glomerulonefrite pauci-imune
(1,7%). Entre comorbidades, observamos que 35% das pacientes tinham
hipertensão arterial; 20% estavam em uso de inibidor da enzima conversa da
Angiotensina (IECA) ou bloqueador de receptor da angiotensina (BRA).
Apresentavam taxa de filtração glomerular média pré-concepção de 101,98
ml/min/1,73m² e níveis de proteinúria média de 0,79g/24h. Quanto aos desfechos
renais, 5,4% apresentaram piora de função renal e 50% atividade de sua
glomerulopatia, constatando-se que em 35,5% dos casos foi preciso alterar o
esquema imunossupressor. Quanto aos desfechos obstétricos, houve 6,7% de
abortamentos, 5,6% de pré-eclâmpsia, 59,2% dos partos foram cesárea, 46,8%
foram partos prematuros e 34,1% dos recém-nascidos (RN) tiveram baixo peso, com
5,4% de óbitos fetais e 10,8% necessitando de internação em unidade de terapia
intensiva (UTI) neonatal. Pacientes que estavam em uso de imunossupressor ao
diagnóstico e aquelas com atividade de sua glomerulopatia na gravidez tiveram mais
partos prematuros (p=0,03) e RN com menor peso ao nascimento (p=0,03). Alguns
tipos histológicos se associaram com maior risco de desfechos fetais, sendo que RN
de pacientes com GESF, nefrite lúpica, e glomerulopatia membranosa tiveram
também mais baixo peso ao nascer quando comparados com aqueles de mulheres
com as demais glomerulopatias. CONCLUSÕES: Em nossa população, observamos
que a gestação em pacientes com glomerulopatias esteve pouco associada à
alteração de função renal, mas associou-se com altos índices de atividade de
glomerulopatia e de desfechos obstétricos. Detectamos ainda maior risco de
desfechos obstétricos naquelas que estavam em uso de medicamento
imunossupressor e que tiveram atividade da glomerulopatia durante a gravidez
INTRODUCTION: It is estimated that globally 6% of women of childbearing age have chronic kidney disease (CKD) and that 3% of pregnancies occur in women with this condition. Pregnancy physiologically promotes an increase in circulating plasma volume, renal plasma flow and glomerular filtration rate, as well as changes in glomerular capillary permeability and tubular reabsorption, thus constitutes an important increase in renal metabolic demand, and the inability to adapt to such demand is related to unfavorable maternal and fetal outcomes. Glomerulopathies are an important etiology of CKD and unfavorable outcomes are associated with pregnancies in women with this condition, especially in situations of prior renal dysfunction and proteinuria; however, this association needs further study, especially on a national level. OBJECTIVES: The primary objectives of this study were: to describe the clinical and laboratory characteristics of glomerulopathies during pregnancy and to evaluate maternal and fetal outcomes during pregnancy in women with this condition. Secondary objectives were: to determine factors associated with maternal and fetal outcomes in pregnancy in patients with glomerulopathies. METHODS: This is an observational retrospective analytical cohort study conducted at a single center (UNIFESP –EPM), based on data collection from medical records of patients followed from 1992 to 2021.RESULTS: We found 60 pregnancies that met the inclusion criteria. The mean age of patients was 28.7 years. The etiological diagnoses corresponded to: lupus nephritis (31.7%), focal segmental glomerulosclerosis (26.7%), minimal change disease (16.7%), IgA nephropathy (8.3%), Alport disease (6.7%), membranous glomerulopathy (3.3%), C1q nephropathy (1.7%) and pauci-immune glomerulonephritis (1.7%). As comorbidities, we observed that 35% of patients had hypertension; 20% were using ACE inhibitors or ARBs. They had a mean preconception glomerular filtration rate of 101.98 ml/min/1.73m² and mean proteinuria levels of 0.79g/24h. As for renal outcomes, 5.4% had a decrease of renal function and 50% presented active glomerular disease, noting that in 35.5% of them it was necessary to change the immunosuppressive regimen. Regarding obstetric outcomes, there were 6.7% of miscarriages, 5.6% of preeclampsia, 59.2% cesarean, 46.8% of premature births and 34.1% of low-birthweight newborns, with 5.4% of fetal deaths and 10.8% needing a neonatal ICU. xvi Patients who were on immunosuppressants at diagnosis and those who had active glomerulopathy during pregnancy had more premature births (p=0.03) and lower birth weight (p=0.03). Some histological types were associated with a higher risk of fetal outcomes, and newborns of patients with FSGS, lupus nephritis, and membranous glomerulopathy also had lower birth weights when compared to those of women with the other glomerulopathies. CONCLUSIONS: In our population, we observed that pregnancy in patients with glomerulopathies was minimally associated with renal dysfunction, but was associated with high rates of glomerulopathy activity and obstetric outcomes. We detected an even greater risk of obstetric outcomes in those who were using immunosuppressants and who had active glomerular disease during pregnancy.
INTRODUCTION: It is estimated that globally 6% of women of childbearing age have chronic kidney disease (CKD) and that 3% of pregnancies occur in women with this condition. Pregnancy physiologically promotes an increase in circulating plasma volume, renal plasma flow and glomerular filtration rate, as well as changes in glomerular capillary permeability and tubular reabsorption, thus constitutes an important increase in renal metabolic demand, and the inability to adapt to such demand is related to unfavorable maternal and fetal outcomes. Glomerulopathies are an important etiology of CKD and unfavorable outcomes are associated with pregnancies in women with this condition, especially in situations of prior renal dysfunction and proteinuria; however, this association needs further study, especially on a national level. OBJECTIVES: The primary objectives of this study were: to describe the clinical and laboratory characteristics of glomerulopathies during pregnancy and to evaluate maternal and fetal outcomes during pregnancy in women with this condition. Secondary objectives were: to determine factors associated with maternal and fetal outcomes in pregnancy in patients with glomerulopathies. METHODS: This is an observational retrospective analytical cohort study conducted at a single center (UNIFESP –EPM), based on data collection from medical records of patients followed from 1992 to 2021.RESULTS: We found 60 pregnancies that met the inclusion criteria. The mean age of patients was 28.7 years. The etiological diagnoses corresponded to: lupus nephritis (31.7%), focal segmental glomerulosclerosis (26.7%), minimal change disease (16.7%), IgA nephropathy (8.3%), Alport disease (6.7%), membranous glomerulopathy (3.3%), C1q nephropathy (1.7%) and pauci-immune glomerulonephritis (1.7%). As comorbidities, we observed that 35% of patients had hypertension; 20% were using ACE inhibitors or ARBs. They had a mean preconception glomerular filtration rate of 101.98 ml/min/1.73m² and mean proteinuria levels of 0.79g/24h. As for renal outcomes, 5.4% had a decrease of renal function and 50% presented active glomerular disease, noting that in 35.5% of them it was necessary to change the immunosuppressive regimen. Regarding obstetric outcomes, there were 6.7% of miscarriages, 5.6% of preeclampsia, 59.2% cesarean, 46.8% of premature births and 34.1% of low-birthweight newborns, with 5.4% of fetal deaths and 10.8% needing a neonatal ICU. xvi Patients who were on immunosuppressants at diagnosis and those who had active glomerulopathy during pregnancy had more premature births (p=0.03) and lower birth weight (p=0.03). Some histological types were associated with a higher risk of fetal outcomes, and newborns of patients with FSGS, lupus nephritis, and membranous glomerulopathy also had lower birth weights when compared to those of women with the other glomerulopathies. CONCLUSIONS: In our population, we observed that pregnancy in patients with glomerulopathies was minimally associated with renal dysfunction, but was associated with high rates of glomerulopathy activity and obstetric outcomes. We detected an even greater risk of obstetric outcomes in those who were using immunosuppressants and who had active glomerular disease during pregnancy.