Диабетическая нефропатия у беременных с сахарным диабетом 1 типа, современный взгляд на проблему

Диабетическая нефропатия (ДН) - специфическое поражение почек при сахарном диабете (СД), которое относительно часто встречается у беременных с прегестационным СД (5,9-26%) и является одним из основных факторов, препятствующих благоприятному течению беременности у этой группы женщин. Выраженная ДН увеличивает риски неблагоприятных исходов беременности как для матери, так и для плода, способствуя прогрессированию хронической болезни почек (ХБП), развитию преэклампсии, большей частоте преждевременных родов, оперативного родоразрешения, повышению перинатальной смертности и неонатальной заболеваемости. В то же время в мире продолжает накапливаться опыт относительно благополучных исходов беременности у женщин с тяжелой ХБП.

В данном обзоре систематизируется мировой и российский опыт планирования и ведения беременности у женщин с СД 1 типа и ДН разной степени выраженности. Обсуждаются значение нефропротективной терапии на преграви-дарном этапе, достижения и поддержания целевых значений артериального давления и гликемии, необходимость наблюдения междисциплинарной командой специалистов для улучшения течения беременности и исхода родов у данной категории больных.

1. Дедов И.И., Шестакова М.В., Майоров А.Ю., и др. Алгоритмы специализированной медицинской помощи больным сахарным диабетом / Под ред. И.И. Дедова, М.В. Шестаковой, А.Ю. Майорова. 9-й вып. // Сахарный диабет. — 2019. — Т. 22. — №S1-1. — C. 1-144. doi: https://doi.org/10.14341/DM221S1

2. Erratum: Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Update Work Group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Kidney IntSuppl (2011). 2017;7(3):1-59. doi: https://doi.org/10.1016Zj.kisu.2017.04.001

3. Damm JA, Asbjornsdottir B, Callesen NF, et al. Diabetic nephropathy and microalbuminuria in pregnant women with type 1 and type 2 diabetes: prevalence, antihypertensive strategy, and pregnancy outcome. Diabetes Care. 2013;36(11):3489-3494. doi: https://doi.org/10.2337/dc13-1031

4. McCance DR, Holmes VA, Maresh MJ, et al. Vitamins C and E for prevention of pre-eclampsia in women with type 1 diabetes (DAPIT): a randomised placebo-controlled trial. The Lancet. 2010;376(9737):259-266. doi: https://doi.org/10.1016/s0140-6736(10)60630-7

5. Ekbom P Damm P, Feldt-Rasmussen B, et al. Pregnancy outcome in type 1 diabetic women with microalbuminuria. Diabetes Care. 2001;24(10):1739-1744. doi: https://doi.org/10.2337/diacare.24.10.1739

6. Боровик Н.В., Потин В.В., Рутенбург Е.Л. Диабетические микрососудистые осложнения (ретинопатия и нефропатия) и беременность // Журнал акушерства и женских болезней. — 2013. — Т. 62. — №2. — С. 75-82.

7. Klemetti MM, Laivuori H, Tikkanen M, et al. Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988-2011. Diabetologia. 2015;58(4):678-686. doi: https://doi.org/10.1007/s00125-014-3488-1

8. The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986. doi: https://doi.org/10.1056/NEJM199309303291401

9. Biesenbach G, Grafinger P Stoger H, et al. How pregnancy influences renal function in nephropathic type 1 diabetic women depends on their pre-conceptional creatinine clearance. J Nephrol. 1999;12(1):41-46. doi: https://doi.org/10.1007/bf00400946

10. Reece EA, Leguizamon G, Homko C. Pregnancy performance and outcomes associated with diabetic nephropathy. Am J Perinatol. 1998;15(7):413-421. doi: https://doi.org/10.1055/s-2007-993968

11. The Diabetes Control and Complications Trial Research Group. Effect of pregnancy on microvascular complications in the diabetes control and complications trial. Diabetes Care. 2000;23(8):1084-1091. doi: https://doi.org/10.2337/diacare.23.8.1084

12. Verier-Mine O, Chaturvedi N, Webb D, et al. Is pregnancy a risk factor for microvascular complications? The EURODIAB Prospective Complications Study. Diabet Med. 2005;22(1 1):1503-1509. doi: https://doi.org/10.1111/j.1464-5491.2005.01682.x

13. Reece EA, Coustan DR, Hayslett JP et al. Diabetic nephropathy: pregnancy performance and fetomaternal outcome. Am JObstet Gynecol. 1988;159(1):56-66. doi 10.1016/0002-9378(88)90494-2

14. Biesenbach G, Grafinger P Zazgornik J, et al. Perinatal complications and three-year follow up of infants of diabetic mothers with diabetic nephropathy stage IV. Ren Fail. 2000;22(5):573-580. doi: https://doi.org/10.1081/jdi-100100898

15. Gordon M, Landon MB, Samuels P et al. Perinatal outcome and long-term follow-up associated with modern management of diabetic nephropathy. Obstet Gynecol. 1996;87(3):401-409. doi: https://doi.org/10.1016/0029-7844(95)00420-3.

16. Imbasciati E, Gregorini G, Cabiddu G, et al. Pregnancy in CKD stages 3 to 5: fetal and maternal outcomes. Am J Kidney Dis. 2007;49(6):753-762. doi: https://doi.org/10.1053/j.ajkd.2007.03.022

17. Biesenbach G, Stoger H, Zazgornik J. Influence of pregnancy on progression of diabetic nephropathy and subsequent requirement of renal replacement therapy in female type I diabetic patients with impaired renal function. Nephrol Dial Transplant. 1992;7(2):105-109. doi: https://doi.org/10.1093/oxfordjournals.ndt.a092077

18. Purdy LP Hantsch CE, Molitch ME, et al Effect of pregnancy on renal function in patients with moderate-to-severe diabetic renal insufficiency. Diabetes Care. 1996;19(10):1067-1074. doi: https://doi.org/10.2337/diacare.19.10.1067

19. Mackie AD, Doddridge MC, Gamsu HR, et al. Outcome of pregnancy in patients with insulin-dependent diabetes mellitus and nephropathy with moderate renal impairment. Diabet Med. 1996;13(1):90-96. doi: https://doi.org/10.1002/(SICI)1096-9136(199601)13:1<90::AID-DIA992>3.0.CO;2-M

20. Rossing K, Jacobsen P Hommel E, et al. Pregnancy and progression of diabetic nephropathy. Diabetologia. 2002;45(1):36-41. doi: https://doi.org/10.1007/s125-002-8242-4

21. Piccoli GB, Clari R, Ghiotto S, et al. Type 1 diabetes, diabetic nephropathy, and pregnancy: a systematic review and meta-study. Rev Diabet Stud. 2013;10(1):6-26. doi: https://doi.org/10.1900/RDS.2013.106

22. Balsells M, Garcia-Patterson A, Gich I, et al. Maternal and fetal outcome in women with type 2 versus type 1 diabetes mellitus: a systematic review and metaanalysis. J Clin Endocrinol Metab. 2009;94(11):4284-4291. doi: https://doi.org/10.1210/jc.2009-1231

23. Bell R, Glinianaia SV, Tennant PW, et al. Peri-conception hyperglycaemia and nephropathy are associated with risk of congenital anomaly in women with pre-existing diabetes: a population-based cohort study. Diabetologia. 2012;55(4):936-947. doi: https://doi.org/10.1007/s00125-012-2455-y

24. Kerssen A, de Valk HW, Visser GH. Forty-eight-hour first-trimester glucose profiles in women with type 1 diabetes mellitus: a report of three cases of congenital malformation. Prenatal Diagnosis. 2006;26(2):123-127. doi: https://doi.org/10.1002/pd.1340

25. Cooper WO, Hernandez-Diaz S, Arbogast PG, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med. 2006;354(23):2443-2451. doi: https://doi.org/10.1056/NEJMoa055202.

26. Doria A. Genetics of diabetes complications. CurrDiab Rep. 2010;10(6):467-475. doi: https://doi.org/10.1007/s11892-010-0147-x

27. Forbes JM, Coughlan MT, Cooper ME. Oxidative stress as a major culprit in kidney disease in diabetes. Diabetes. 2008;57(6):1446-1454. doi: https://doi.org/10.2337/db08-0057

28. Bramham K. Diabetic nephropathy and pregnancy. Semin Nephrol. 2017;37(4):362-369. doi: https://doi.org/10.1016/j.semnephrol.2017.05.008

29. Jensen DM, Damm P Ovesen P et al. Microalbuminuria, preeclampsia, and preterm delivery in pregnant women with type 1 diabetes: results from a nationwide Danish study. Diabetes Care. 2010;33(1):90-94. doi: https://doi.org/10.2337/dc09-1219

30. Bell R, Bailey K, Cresswell T, et al. Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and type II diabetes. BJOG. 2008;115(4):445-452. doi: https://doi.org/10.1111/j.1471-0528.2007.01644.x

31. Hiilesmaa V, Suhonen L, Teramo K. Glycaemic control is associated with preeclampsia but not with pregnancy-induced hypertension in women with type I diabetes mellitus. Diabetologia. 2000;43(12):1534-1539. doi: https://doi.org/10.1007/s001250051565

32. Clausen P Ekbom P Damm P et al. Signs of maternal vascular dysfunction precede preeclampsia in women with type 1 diabetes. J Diabetes Complications. 2007;21(5):288-293. doi: https://doi.org/10.1016/jjdiacomp.2006.03.004

33. Мозговая Е.В. Диагностика и медикаментозная коррекция эндотелиальной дисфункции при гестозе: Автореф. дис. ... докт. мед. наук. — СПб., 2004. — 40 с. Доступно по: https://search.rsl.ru/ru/record/01003244942. Ссылка активна на 14.04.2020.

34. Kelly CB, Hookham MB, Yu JY, et al. Subclinical first trimester renal abnormalities are associated with preeclampsia in normoalbuminuric women with type 1 diabetes. Diabetes Care. 2017;41(1):120-127. doi: https://doi.org/10.2337/dc17-1635

35. Sandvik MK, Iversen BM, Irgens LM, et al. Are adverse pregnancy outcomes risk factors for development of end-stage renal disease in women with diabetes? Nephrol Dial Transplant. 2010;25(11):3600-3607. doi: https://doi.org/10.1093/ndt/gfq275

36. American Diabetes Association. 14. Management of diabetes in pregnancy: standards of medical care in diabetes-2019. Diabetes Care. 2019;42(Suppl 1):S165-S172. doi: https://doi.org/10.2337/dc19-S014

37. Печерина Л.В. Эффективность низкомолекулярных гепаринов в комплексной терапии гестоза: Автореф. дис. ... канд. мед. наук. — СПб., 2004. — 24 с. Доступно по: https://search.rsl.ru/ru/record/01002726904. Ссылка активна на 14.04.2020.

38. Nielsen LR, DammP, MathiesenER. Improved pregnancy outcome in type1 diabetic women with microalbuminuria or diabetic nephropathy: effect of intensified antihypertensive therapy? Diabetes Care. 2009;32(1):38-44. doi: https://doi.org/10.2337/dc08-1526

39. Schaefer-Graf U, Napoli A, Nolan CJ. Diabetes in pregnancy: a new decade of challenges ahead. Diabetologia. 2018;61(5):1012-1021. doi: https://doi.org/10.1007/s00125-018-4545-y 54.

40. Wahabi HA, Alzeidan RA, Esmaeil SA. Pre-pregnancy care for women with pre-gestational diabetes mellitus: a systematic review and meta-analysis. BMC Public Health. 2012;12:792. doi: https://doi.org/10.1186/1471-2458-12-792

41. Piccoli G, Zakharova E, Attini R, et al. Pregnancy in chronic kidney disease: need for higher awareness. A pragmatic review focused on what could be improved in the different CKD stages and phases. J Clin Med. 2018;7(11):415. doi: https://doi.org/10.3390/jcm7110415

42. Боровик Н.В., Ярмолинская М.И., Главнова О.Б., и др. Новые возможности использования цистатина С как предиктора ранней диагностики диабетической нефропатии // Журнал акушерства и женских болезней. — 2019. — Т. 68. — №3. — С. 15-24.] doi: https://doi.org/10.17816/JOWD68315-24

43. Li DK, Yang C, Andrade S, et al. Maternal exposure to angiotensin converting enzyme inhibitors in the first trimester and risk of malformations in offspring: a retrospective cohort study. BMJ. 2011;343:d5931. doi: https://doi.org/10.1136/bmj.d5931

44. Bullo M, Tschumi S, Bucher BS, et al. Pregnancy outcome following exposure to angiotensin-converting enzyme inhibitors or angiotensin receptor antagonists: a systematic review. Hypertension. 2012;60(2):444-450. doi: https://doi.org/10.1161/HYPERTENSIONAHA.112.196352

45. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period. NICE guideline 3 [cited 26 August 2015]. National Institute of Clinical and Health Excellence; 2015. Available from: https://www.nice.org.uk/guidance/ng3.

46. Carr DB, Koontz GL, Gardella C, et al. Diabetic nephropathy in pregnancy: suboptimal hypertensive control associated with preterm delivery. Am J Hypertens. 2006;19(5):513-519. doi: https://doi.org/10.1016/jamjhyper.2005.12.010

47. Nielsen LR, Muller C, Damm P et al. Reduced prevalence of early preterm delivery in women with type 1 diabetes and microalbuminuria: possible effect of early antihypertensive treatment during pregnancy. Diabet Med. 2006;23(4):426-431. doi: https://doi.org/10.1111/j.1464-5491.2006.01831.x

48. Fullerton B, Jeitler K, Seitz M, et al. Intensive glucose control versus conventional glucose control for type 1 diabetes mellitus. Cochrane Database Syst Rev. 2014;2014(2):CD009122. doi: https://doi.org/10.1002/14651858

49. Kahler P, Grevstad B, Almdal T, et al. Targeting intensive versus conventional glycaemic control for type 1 diabetes mellitus: a systematic review with meta-analyses and trial sequential analyses of randomised clinical trials. BMJ Open. 2014;4(8):e004806. doi: https://doi.org/10.1136/bmjopen-2014-004806

50. Shurraw S, Hemmelgarn B, Lin M, et al. Association between glycemic control and adverse outcomes in people with diabetes mellitus and chronic kidney disease: a populationbased cohort study. Arch Intern Med. 2011;171(21):1920-1927. doi: https://doi.org/10.1001/archinternmed.201 1.537

51. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. N Engl J Med. 1993;329(14):977-986. doi: https://doi.org/10.1056/NEJM199309303291401

52. Газизова Г.Р. Маркеры воспаления диабетической нефропатии у беременных с сахарным диабетом 1 типа: Автореф. дис. ... канд. мед. наук. — СПб., 2015. — 22 с. Доступно по: https://search.rsl.ru/ru/record/01005570273. Ссылка активна на 14.04.2020.

53. Brown JS, Wessells H, Chancellor MB, et al. Urologic complications of diabetes. Diabetes Care. 2005;28(1):177-185. doi: https://doi.org/10.2337/diacare.28.1.177

54. Wessells H, Braffett BH, Holt SK, et al. Burden of urological complications in men and women with long-standing type 1 diabetes in the diabetes control and complications trial/epidemiology of diabetes interventions and complications cohort. Diabetes Care. 2018;41(10):2170-2177. doi: https://doi.org/10.2337/dc18-0255

55. Mazor-Dray E, Levy A, Schlaeffer F, Sheiner E. Maternal urinary tract infection: is it independently associated with adverse pregnancy outcome? J Matern Fetal Neonatal Med. 2009;22(2):124-128. doi: https://doi.org/10.1080/14767050802488246

56. Meuwese CL, Carrero JJ. Chronic kidney disease and hypothalamic-pituitary axis dysfunction: the chicken or the egg? Arch Med Res. 2013;44(8):591-600. doi: https://doi.org/10.1016/j.arcmed.2013.10.009

57. Finkelstein FO, Shirani S, Wuerth D, et al. Therapy insight: sexual dysfunction in patients with chronic kidney disease. Nat Clin Pract Nephrol. 2007;3(4):200-207. doi: https://doi.org/10.1038/ncpneph0438

58. Приказ Министерства здравоохранения и социального развития Российской Федерации № 736 от 3 декабря 2007 г. «Об утверждении перечня медицинских показаний для искусственного прерывания беременности». Доступно по: https://www.rosminzdrav.ru/documents/7780-prikaz-minzdravsotsrazvitiya-rossii-736-ot-3-dekabrya-2007-g. Ссылка активна на 14.04.2020.

59. Piccoli GB, Minelli F, Versino E, et al. Pregnancy in dialysis patients in the new millennium: a systematic review and metaregression analysis correlating dialysis schedules and pregnancy outcomes. Nephrol Dial Transplant. 2016;31(11):1915-1934. doi: https://doi.org/10.1093/ndt/gfv395

60. Ibarra-Hernandez M, Alcantar-Vallin M, Soto-Cruz A, et al. Challenges in managing pregnancy in underserved women with chronic kidney disease. Am J Nephrol. 2019;49(5):386-396. doi: https://doi.org/10.1159/000499964

61. Webster P Lightstone L, McKay D, et al. Pregnancy in chronic kidney disease and kidney transplantation. Kidney Int. 2017;91(5):1047-1056. doi: https://doi.org/10.1016/j.kint.2016.10.045

62. Cabiddu G, Spotti D, Gernone G, et al. A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology. J Nephrol. 2018;31(5):665-681. doi: https://doi.org/10.1007/s40620-018-0499-x

63. Kidney Disease: Improving Global Outcomes (KDIGO) Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009;9(Suppl 3):1-155. doi: https://doi.org/10.1111/j.1600-6143.2009.02834.x