Hypercalcaemia in pregnancy in a renal transplant recipient with secondary hyperparathyroidism

zyxwvutsrq zyxwvutsrq zyxwvuts zyxwvutsrq 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 zyxwvu zyx 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 zyxwvutsr zyxwvut zyxwvutsrq zyxwvu zyxwvutsrqpon zyxwvutsrqpo 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. zyxwvutsrqpo 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- zyxwvu zyxwvu zy z 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 zyx zyxwvutsrqpon zyxwvuts zyx zyxwvutsrq 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 zyxwvutsr 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 zyxwvutsr zyxwvutsr zyxwvu zyxwvu zyxwvut z zyxwv 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 zyxwvuts Au W. Y. W. (1983) Inhibition by 1.25 dihydroxycholccalciferol of hormonal secretion of rat parathyroid gland in organ culture. Cdcij Tissue I n t 36, 384-389. zyxwv zyxw zyxw z Hypercalcaemia in pregnatiry after renal fransplanfutiori 1053 H . F. (1970) Determination of vitamin D and its metabolites in plasma from normal and anephric man. Biorkem J 182, 55-69. Slatopolaky E., Weerts C . , Thielaii J . . Horst R . , Harter H. and Martin K . J. (1984) Marked suppression of secondary hyperparathyroidism by intravenous administration of 1,25-dihydroxicliolecalcifcrol in uremic paticnts. J Chi Invest 74, 2136-2143. Turncr M., BarrC P. E., Benjamin A , . Goltznian 1). B Gascon-BarrC M. (1988) Docs the maternal kidney contributc to the increased circulating I ,25-dihydl-oxivitamin D concentrations during pregnancy'? .Mirwral Electrolyte Metah 14. 240-252. WeismanY..VargasA.,Duckctt G.,ReitcrE. & R o o t A . W. (1978) Synthesis o f 1,ZS-dihydroxyvitamin D in the ncphrectomized pregnant rat. Endocriti010gy 103, 1992-1996. Weisman Y., Hare11 A , , Edelstein S.,David M., Spirer Z. & Golander A. (1979) la. 25-dihydroxyvitamin Di and 24,2j~dihydroxyvitaininD, in vitm syn- thesis by human dccidua and placenta. Nnture 281, 317-319. Wesckler W. K.,Henry H . L.. & Norman A . W. (1977) Studies of the mode of action of choleealciferol: subcellular localization of 1.25-dihydroxyvitamin D, in chicken parathyroid gland. Arch Biochern Biuphys 183, 168-175. Whitsett J. A.. H o M.. Tsang R. C., Norman E. J. & Adams K. G. (1981) Synthesis of 1.25-dihydroxyvitamin 0, by human placenta in vitro. J Clin Erzdocrinol Metah 53, 384-488. Zerwekh J. E. & Rreslau N. A . (1986) Human placental production of 1a , 25-dihydroxyvitamir~D,: biochemical characterization and production in normal subjects and patients with pseudo-hypoparathyroidism. J Clin Endocrirzol Metuh 62, 192-196. zyxwvut zyxwvutsrqp zyxwvuts zyxwvuts zyxwvutsrq Received 3 October 1989 Accepted 24 April 1990