Analysis Of Pregnancy Outcomes In Patients With ANCA-associated Glomerulonephritis

Objective:Antineutrophil cytoplasmic antibody-associated glomerulonephritis(AAGN)is infrequently seen in women of child-bearing age.There is limited published literature regarding pregnancy in AAGN.In this study,5 patients with AAGN were followed up to investigate pregnancy complications and fetal outcomes and their risk factors.Methods:Five women with MPO-ANCA positive AAGN who achieved complete renal remission were collected in our unit.Prednisone or prednisone plus azathioprine(AZA)was administered during pregnancy.Vasculitis activity was scored by BVAS.Pregnancy-related complications included relapse of AAGN,gestational hypertension,progression of chronic kidney disease(CKD),or acute kidney injury.Adverse fetal outcomes include premature delivery,fetal loss,and intrauterine growth retardation(IUGR).Results:We described 5 patients who were positive for MPO-ANCA,and all clinical types were MPA.Kidney biopsy pathology suggested 3 cases were mixed type,and 2 cases were focal type.All the 5 patients had planned pregnancy,the age of pregnancy range from 24 to 33 years,the median duration of AAGN before pregnancy was 60(27,144)months,and the mean time to renal remission was 32(12,96)months.EGFR of all the patients before pregnancy was more than 60mL/min/1.73m2,and proteinuria is less than 0.5g/24h.Five pregnancies were maintained with prednisone monotherapy and two with prednisone plus AZA.Serum MPO-ANCA was positive in 4 pregnancies,one experiencing a relapse during pregnancy with MPO-ANCA high titer positive before pregnancy and the fetus was delivered by cesarean section due to premature rupture of membranes.One patient with hypertension before pregnancy developed severe hypertension in the first pregnancy and terminated the pregnancy at 8 weeks of gestation.The second pregnancy was complicated with preeclampsia with fetal IUGR and premature delivery.Six of the seven pregnancies were carried to term,and only one was premature.The mean birth weight was 3.1(2.3,3.4)kg.The median follow-up after the last conception was 22(19,25)months,one with persistent MPO-ANCA low titer positive during pregnancy relapsed 2 month after delivery.At the end of the follow-up,one patient with AAGN relapse during pregnancy progressed from CKD stage 2 to CKD stage 3b,and the patient with hypertension before pregnancy progressed from CKD stage 1 to CKD stage 4.Conclusions:Patients in remission of AAGN at conception can have a successful pregnancy.Patients with ANCA positive serum and hypertension before pregnancy increase the risk of AAGN relapse,deterioration of renal function and adverse fetal outcomes during pregnancy.