高海拔地区妊娠高血压伴肾损害的临床特点及影响因素

摘要

Objective To investigate the incidence and clinical features of women with hypertension disorders of pregnancy complicated with renal impairment at high altitude,and explore the impact of proteinuria,renal insufficiency and preexisting chronic kidney disease (CKD) on these patients.Methods A pool of 1790 pregnant women admitted to Yunnan Diqing Tibetan Autonomous Prefecture People's Hospital from September 2017 to September 2018.Data of 123 patients who met the criteria of hypertension disorders in pregnancy were collected and retrospectively studied.Their clinical characteristics and pregnancy outcomes were analyzed.Patients with hypertension and renal impairment,simple hypertension patients as well as normal pregnant women were compared.Hypertensive patients with proteinuria,renal insufficiency (Scr ＞ 70 μmol/L) and preexisting CKD were also compared with simple hypertension patients.The impact of proteinuria,renal insufficiency and preexisting CKD on patients with hypertension disorders of pregnancy was assessed by multivariate logistic analysis.Results Of these 123 patients,61 cases (49.6％) had renal impairment,57 cases (46.3％) had proteinuria,15 cases (12.2％)had renal insufficiency and 6 cases (4.9％) had preexisting CKD.Compared with normal pregnant women and simple hypertension patients,patients with hypertension and renal impairment had higher blood pressure,Scr,primipara rate and caesarean section rate (all P ＜ 0.05),lower gestational age,neonatal Apgar scores and plasma albumin level (all P ＜ 0.05),as well as adverse pregnancy outcomes,including premature birth,stillbirtheonatal death,intrauterine growth restriction,infants of low-birth weight and admission to the neonatal intensive care unit (NICU) (all P ＜ 0.05).The clinical features and pregnancy outcomes of 57 patients with proteinuria correlated with the proteinuria.Compared with non-nephrotic syndrome patients and patients without proteinuria,patients with nephrotic syndrome (NS) had lower plasma albumin level and higher rates of premature birth,infants of low-birth weight and admission to NICU (all P ＜ 0.05).Among 15 patients with renal insufficiency,there were 13 mild abnormal cases (70 μmol/L ＜ Scr≤ 123 μmol/L,86.7％).Compared with those with normal renal function,patients with renal insufficiency had higher Scr,uric acid and rates of preeclampsia/eclampsia,intrauterine growth restriction,infants of low-birth weight and admission to NICU,while lower plasma albumin level (all P ＜ 0.05).Among 6 patients with preexisting CKD,4 had NS,2 had renal insufficiency,5 delivered before 37 weeks,and 2 infants died.Logistic regression analysis showed that NS (0R=4.863,P=0.032),renal insufficiency (OR=7.550,P=0.017) and systolic pressure (OR=1.061,P=0.002) were independent risk factors for adverse pregnancy outcomes among patients with hypertension disorders in pregnancy.Conclusions Renal impairment is common among patients with hypertension disorders in pregnancy at high altitude and has adverse effects on pregnancy outcomes.Massive proteinuria,renal insufficiency and systolic pressure are risk factors for these patients.%目的 了解高海拔地区妇女妊娠高血压(简称妊高征)伴肾损害的发生率及临床特点,探讨蛋白尿、肾功能异常及慢性肾脏病基础对妊高征患者妊娠结局的影响.方法 采用回顾性分析方法,收集2017年9月至2018年9月于云南迪庆藏族自治州人民医院产科住院的1790例孕产妇中诊断符合妊高征的患者的临床资料并从中筛选肾损害患者.选取同期住院的227例正常妊娠孕产妇为对照组.比较妊高征伴肾损害患者与单纯妊高征及正常孕产妇,以及合并蛋白尿、肾功能异常及慢性肾脏病基础的妊高征患者与单纯妊高征患者在临床特征及妊娠结局方面的差异.多因素Logistic回归方法评估蛋白尿、肾功能异常及慢性肾脏病基础对妊高征患者妊娠结局的影响.结果 123例妊高征患者,61例(49.6％)伴有肾损害,其中57例(46.3％)伴蛋白尿,15例(12.2％)伴肾功能异常,6例(4.9％)存在慢性肾脏病基础.与单纯妊高征及正常妊娠孕产妇相比,妊高征伴肾损害患者血压、血清肌酐、初产妇比例、剖腹产比例、早产、死胎/新生儿死亡、宫内发育受限、低体重儿及入住新生儿重症监护室(NICU)比例较高(均P＜ 0.05),血清白蛋白、终止妊娠周数及新生儿Apgar评分较低(均P＜0.05).57例合并蛋白尿的患者临床指标及妊娠结局随蛋白尿增加呈恶化趋势.与非肾病综合征组及无蛋白尿组比较,肾病综合征组血清白蛋白降低,早产、低体重儿及入住NICU比例均增加(均P＜0.05).15例肾功能异常患者中13例(86.7％)为轻度异常(70 μmol/L＜肌酐≤123 μmol/L).与肾功能正常组相比,肾功能异常组血清肌酐、尿酸、发生子痫前期/子痫、胎儿富内发育受限、低体重儿及入住NICU比例较高,血清白蛋白水平较低(均P＜ 0.05).合并慢性肾脏病的6例患者的蛋白尿程度在妊娠期均有增加,其中4例出现肾病综合征,2例肾功能异常,5例早产,2例死胎/新生儿死亡.多因素Logistic回归分析提示肾病综合征(OR=4.863,P=0.032)、肾功能异常(OR=7.550,P=0.017)及收缩压(OR=1.061,P=0.002)是妊高征患者不良妊娠结局的独立危险因素.结论 高海拔地区妊高征伴肾损害发病率较高且影响妊娠结局.大量蛋白尿、肾功能异常及收缩压水平是妊高征患者不良妊娠结局的独立危险因素.