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Bnmh Journul of Obsteirrcs arid Gynurcology
November 19Y0, Vnl. 97. pp 1049-1053
Hypercalcaemia in pregnancy in a renal transplant
recipient with secondary hyperparathyroidism.
Case report
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G. A. FROMM, C. A . LABARRERE, J . RAMIREZ C. A. MAUTALEN;
L. PLANTALECH, 0. ALTHABE, C. CASCO, J. FERRARIS
Case report
A 28-year-old woman was seen in her first pregnancy in 1984. At 23 years of agc she received a
renal transplant from her HLA identical
brother. During thc 30 months before the transplant shc was maintained on hacmodialysis
because of end-stage renal disease secondary to
chronic glomeruloncphritis dating from 9 years
of agc. Since transplantation shc had taken
azathioprine 50 mg daily and prednisonc 10 mg
daily. Blood pressure and renal function were
normal. After 3.5 years from transplantation,
mild hypercalcaemia and increased levels of
serum parathyroid hormone (PTH) were found.
A low calcium diet and bisodium phosphate in
doses equivalent to 2.2 giday of phosphorus
were added t o hcr cxisting treatment. and she
Hospital Italiano, Gascon 450. 1181 Bnenos Aires,
Argentina
Department of Endocrinologl
G A FROMM
I PLANTALECH
Department of Pathologj
C A LABARRERE
Department of Pediatric hephrolow
.IRAMIREZ
J FbRRAKIS
Department of Obstetrics
0 ALTHABC
Centro de Osteopatias Metabolicas, Saavedra 189,
1083 Biienos Aires
C A MAUI'ALtN
C CAW0
Corrcspondcnce C A Labairere MD Center lor
Reproduction and Iiansplantatioii Inimunologv,
Methodist Hospital of Indiana. 1701 N Senate Blvd,
Indianapolis. Indiana 16202, USA
had a satisfactory clinical and humoral course
during the following 15 months.
A t her first visit after conception (at 9 weeks
gcstation) her serum calcium was raised (Fig. 1).
The clinical course was satisfactory up to 25
weeks gestation. at which time her blood pressure began to increase (140i85 mm Hg) conipared with her first trimester normal values. 'The
levels of ionic serum calcium and serum 1,25-dihydroxy vitamin D (1,25(OH):D) also increased
compared with normal values.
At 28 weeks gestation she was admitted to
hospital because her blood pressure was 145195
tnm Hg. Hydralazine (200 rngi24 h) and
lor-methyldopa (1 gi24 h) were added t o her
treatment.
At 30 weeks gestation, total serum calcium
had increased to 3.65 mmolil from previous
levels of 2-93 mmol/l. Bisodium phosphate was
discontinued and an intravenous infusion of
2000 ml per day (213 glucose 5% ; 1/3 NaCl0.9'%)
with salinon calcitonin (100 units cvcry 4 h) were
given. The dose of salmon calcitonin was
incrcascd slowly during the next 18 days up to
2400 unih per day and the serum calcium diminished to 268-2.72 mmol/l (Fig. 1).
At 33 weeks gestation the creatinine clearance
decreased (82-1 mlimin), proteinuria appeared
(1 gi24 h). and the diastolic blood pressure was
pcrsistently at 100 mm Hg. The pregnancy was
terminated by caesarcan section and a 1600g
female baby was born. Clinical and neurological
examination of the baby were normal, and
mother and child had an uneventful immediate
post-partum course.
At 19 weeks after delivery, total and ionic
serum
calcium. urinary
calcium
and
1,25(OH),D levels were in the normal range,
but serum PTH values had increased to
310 pg/inl.
1049
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1050
G. A . Fromm etal.
Predriisone 1
rnqlday
It8E--=b!Lb
1.V Salmon 2o
calcitonin lo[&
Uldav x lo'
14
Total
Serum
12
C d C lW l
mgldl
10
8
7 r
Ionic
serum
calcium
I
I
6
rngldl
4
The histological sections were studied with
haematoxylin and eosin, Periodic-Acid-Schiff
(PAS) and Masson's trichrome. Immunohistochemical studies for 1 >2S(OH),D3 were performed in 5 pm sections from the placenta in ten
paraffin cmbcddcd blocks using an immunoperoxidase procedure described previously
(Labarrere ef (11. 1985). Sections were incubated
with rabbit antihuman antibody to I ,25(OH),D3
(Hummer et al. 1985) at a 1:1000 dilution. Swine
antirabbit TgG (1:50) was used as sccond antibody, and rabbit PAP complexes (1:50) (both
from Dakopatts, Denmark) were subsequently
used. The immune reaction was devclopcd with
diaminobcnzidine (Sigma) and hydrogen peroxide. All antisera were diluted in phosphate bufIcr saline (PBS, pH 7.4) which was also used for
washes between incubation steps. To enhance
immunoreactivity which may be lost by formalin
fixation, sections werc submitted to trypsin
digestion as described prcviously (Labarrere et
al. 1985). The following controls were used to
chcck the validity of the procedure: (i) omission
of the primary antiserum; (ii) use of nonimmune rabbit serum as primary antibody; (iii)
preabsorption of the primary antibody with its
respective antigen (1:25(OH),D3).
Ten placentas of similar gestational age, from
women free of any disease hefore, during or
after pregnancy served as controls. All these placentas had villous maturation similar to that in
our patient and no evidence of infection.
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Serum
150
1.25 (OH12 D loo
odml
50
Irmesrer
Pregnancy
Post-pregnancy
Fig. 1. Marked hypercalcaemia associated with a
decrease of seruni parathyroid hormone (PTII) in the
third trimester of pregnancy. Conversion factors to SI
units. Serum calcium: mmol/lx4 = mgidl; plasma
phosphatc mmol/l X 3.1 = mgidl.
Irivestigatians
Placental .fin,dings
Serum and urinary calcium were determined by
atomic absorption spectrophotometry and ionic
serum calcium was determined with an ionselective clectrode (normal values: 1-02-1.21
mmolil). Plasma phosphorus and creatinine
were incasurcd by standard methods.
Serum PTH was determined by radioimmunoassay using an antiserum that rccogniscs the mid
and carboxy terminal fragment of the PTFI molecule. As tracer and standard the fragment
43-68 of the molecule was used (normal values:
20-90 pg/ml). Serum 1,2S(OH),D was measured
using thc mcthod described by Sheparcl el (11.
(1979); the normal values are between 30 and 60
pgiml; at the end of the first trimester of pregnancy the upper limit increases normally to 80
pgiml and during the third trimester the normal
range is between 60 and 100 pg/ml.
The placenta was studied by light microscopy
as described previously (Labarrere et 01. 1985).
The placenta weighed 245s and mcasurcd
1 5 x 1 2 ~ cm.
2
Histologically the villi were
normal in appearancc, but showcd a high proportion of fibrinoid necrosis. Tlie placcnta also
had areas of anchoring villitis (Labarrere &
Althabe 1985) in the basal plate.
The imniunostaining with 1,2S(OH),D3 antibody showed a dark brown cytoplasmatic reactivity in most of the cytotrophoblastic cells in the
septa and in the basal plate (interstitial cytotrophoblast) (Faulk and McIntyre 1983) (Figs. 2a
and b).
No immunoactivity was observed in interstitial cytotrophoblastic cells of the normal placentas used as controls. A weak reactivity was
observed in stromal cells and syncytiotrophoblast of some villi in controls as well as in the
studied case (data not shown). The immunoreactivity was uniformly negative in all the con-
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Hypercalcaernia in pregnancy after renal irarzsplantarion
1051
In the present report an increase of total and
ionic serum calcium and serum 1,25(OH),D was
observed at the beginning of the third trimester
of pregnancy associated with serum PTH levels
below those observed in the first part of gestation (Fig. 1). After delivery, total and ionic
serum calcium and 1,25(OH),D levels decreased
to normal and serum P T H increased. The disturbance in circulating levels of total and ionic
serum calcium and 1,2S(OH)2Dobserved in our
patient may reflect placental rather than rcnal
function. Indeed, 1.2.5(OH),D (Weisman et al.
1978) and 1,2S(OH),D3 (Gray et id. 1979) have
been found in plasma of nephrectomized prcgnarit rats.
In normal human prcgiiancy an increase in circulating 1.25(OH),D has been observed after 6
weeks gestation (Reddy et a[. 1983) and this
reaches a plateau at the end of the first Lrimester
(Reddy et a/. 1983: Gertner et al. 1986). Cushard
et al. (1972) found an increase in serum PTH
during the third trimester of human pregnancy,
but the most recent studies have not confirmed
this. Several authors have found decreased
levels of serum PTH during pregnancy (Reddy et
al. 1983; Gertner et al. 1986; Davis ef al. 1988).
The oppositc changes in serum 1,25(01i),D and
serum PTH may be explained by thc presence
of cytoplasmic and nuclear receptors for
1,2S(OH)>Din parathyrvid glands (Wesckler et
al. 1977), and by the decrease in scrum PTH due
lo the increased serum 1,25(0H)J). This effect
has been obscrvcd in rats (Au 1984) as well as in
the human (Slatopolsky et af. 1984; Breslau &
Zerwekh 1986).
Although high levels of PTH were found
during and after pregnancy, this rise was associated with calcium levels near the uppcr limits or
in the normal range. A relative decrease in
serum P T H was associated with the marked
hypercalcaemia observed in the third trimester.
Although 1,2S(OH)?Dwas not measured at the
time of the hypercalcaemia, high levels wcre
detected during the third trimester. The normal
values for 1,25(OH),D found after delivery, the
return to normocalcaeinia and the increase in
serum PTH suggest a placental origin for the
1,2S(OH),D.
'iumer et al. (1988) reported a patient with
end-stage renal disease and severe secondary
hyperparathyroidism who conceived after 10
years of chronic haemodialysis and gave birth to
a pretcrm baby at 25 wecks gestation. Interestingly, increasing serum calcium conccntrations
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Figs. 2a and b. A dark cytoplasmatic reactivity is seen
in most of the cytolrophoblastic cells in a septa
(interstitial cytotrophoblast). No nuclcai-rcactivity is
found in any cell. 1.25(OH),D3 antibody was used as
primary antiserum. Tininunopcroxidasc stain,
haernatoxylin counterstain (X400).
trol procedures, including the use of absorbed
antiscrum.
Discussion
Since Murray et al. (1963) reported the first
observation of a patient with a renal transplant
who had two successful pregnancies, many other
similar cases have been published. Hou (1985) in
a review article mentioned 1200 cases.
Pcrsistcnt hypercalcaemia due to secondary
hyperparathyroidism after kidney transplantation is a frequent observation (Cundy et al.
1983). We found only one report (Delmonico el
al. 1976) in which a patient with a renal transplant underwent a subtotal parathyroidectomy
due to severe hypercalcacmia in the second trimcstcr of pregnancy. It was prcdicted that this
would be a more frequent occurrence as the
number ol successlul renal transplants in women
iricreascs.
1052
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G. A . Fromm et al.
were noted after 22 weeks gestation, despite discontinuation of previous oral calcium supplementation trcatment, and oral 1,25(OH),I>,
therapy was thcn discontinued. Following
delivery, the patient's serum calcium concentration fell and oral calcium and 1,2S(OH),D,
treatment had to be resumcd. Although her
serum 1,25(OH),D concentrations without
exogenous supplementation did not increase significantly after 23 and 24 weeks gestation, they
were almost twice her own basal values. Since
the patient was delivered at 25 weeks gestation,
the possibility of a further increase in the conccntrations of scrum calcium and 1,2S(OH),D
later during the third trimester, as was found in
our patient, cannot be excluded.
Many authors (Weisman et al. 1979; Whitsett
et al. 1981; Delvin el al. 1985; Zerwekh &
Breslau 1986) reported the production of
1,25(OH),D by human placental tissue in vitro.
Wcisman et al. (1979) reported the production of
1,2S(OH),D by the placental decidua and Zerwekh &L Breslau (1986) observed the presence of
2S-OH-D,-la-hydroxylasc in thc mitochondria
of fetal trophoblastic cells. No rcports havc bccn
published using immunohistochemical techniques to locate the precise site of 1.25(OH),D
in the placenta. Thc rccognition of the placental
cytotrophoblastic cells in the basal plate and
septa (interstitial cytotrophoblast) in our paticnt
as the probable site of synthesis of 1,2S(OH)?D3
is a contribution to the study of this problcm.
Breslau N. A. & Zerwekh J . E. (1986) Relationship of
estrogen and pregnancy to calcium homeostasis in
pseudohypoparathyroidisni. J Clin Endocrind
Metab 6 2 , 6 5 1 .
Cundy T., Kanis J. A., Heynen G., Morris P. J. &
Oliver U . D. (1983) Calcium metabolism and
hyperparathyroidism after renal transplantation.
Q J Med 52, 67-78.
Cushard W. G . Jr., Creditor M. A . , Canterbury J. M.
& h i s s E. (1972) Physiologic hyperparathyroidism in pregnancy. J Clin Endocrinol Metab 34,
767-771.
Davis 0. K., Hawkins U. S., Kuhin L. P.. Posillico J .
T., Brown E. M. & Schiff I. (1988) Serum parathyroid hormone (PTH) i n pregnant women determined by an in~muiioradiometricassay lor intact
PIH. J Clin Endocrine/ Metab 67, 850-852.
Dclmonico F. I>., Ncer R. M., Cosimi A . R . , Rarncs
A. B. &Russell P. D. (2976) Hyperparathyroidism
during pregnancy. Am J Surg 131,328-337.
Delvin E. E.. Arabian A , , Glorieux F. H . & Mainer
0. A. (1985) In vitro metabolism of 25-hydroxycholccalcifcrol by isolated cells from human
decidua. .I Clin Endocrinol Met& 60, 880-885.
Faulk W. P. P; McIntyre J . A. (1983) Immunological
studies of human trophoblast: markers, suhsets
and functions. Imnzunol Rev 75, 139-175.
Gertner J. M.. Coustan D. R . , Kligcr A. S., Mallettc
L. E., RavinN. & Broadus A . E. (1986)Prcgnancy
as state of physiological absorptive hypercalciuria.
A m .I Med 81, 451-456.
Gray T. K . ; Lester G. E. & Lorenc R . S. (1979) Evidence for extra-renal In.-hydroxylation of 25hydroxyvitamin D3 in pregnancy. Science 204,
1311-1313.
H o u S. (1985) Pregnancy in women with chronic renal
disease. N Eirgl J M e n 312, 836-839.
Hummer L., Christiansen C. & Tjelleseri L. (1985)
Discrepancy between serum 1.25-dihydroxicholccalciferol nicasurcd by radioiinmunoassay and
cytosol radioreccptor assay. Srand J Clin Luh
Iil\>est 45, 725-733.
Laharrcre C. & Althabe 0. (1985) Chronic villitis of
unknown etiology and maternal arterial lesions in
preeclamptic pregnancies. Eur J Ubstet Gynaerof
Reproil B i d 20, 1-11,
Laharrcrc C, Alonso J., Manni J.. Domenichini E. RC
Althabe 0. (1985) Immunohistocheniical findings
in acute atherosis associated with intrauterine
growth retardation. Am .I Xeprod Inrmurzul Microh i d 7, 149-155.
Murray J. E., Reid D. E . , Harrison J . H. & Merrill J.
P. (1963) Successful pregnancies aftcr human renal
transplantation. N Engl J Med 269, 311-343.
Reddy G. S.,NornianA. W.. WillisD. M.. Goltzmann
D . , Guyda H., Solomon S.,Philips D. K., Bishop
J. E. & Maycr E. (1983) Regulation of vitamin D
metabolism in normal human pregnancy. J Clin
Enducrinol Metubol56, 363-370.
Shcpard R. M., Horst R. L., Hamstra A. J. & De Luca
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Acknowledgments
We are indebted to D r Cristina Tau who pcrformed the serum determinations
of
1,2S(OH)2Din the Laboratoire des Tissues Calcifics CNRS U A 583 of the Hospital for Sick
Children of Paris, Francc; to Prof Stanley Wallach for his advice; to Dr Claus Christianscn for
the remittance of 1,2S-dihydroxycholecalcifcrol
antiserum used in the placental investigations; to
D r Eduardo Slatopolsky for providing the PTH
antiserum and to the Perez Companc Foundation for allowing us to work in their laboratory. We thank Drs W. Page Faulk and John A.
McIntyre for the critical review and discussion of
the manuscript.
References
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Hypercalcaemia in pregnatiry after renal fransplanfutiori 1053
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Received 3 October 1989
Accepted 24 April 1990